DELTA OMICRON
INTERNATIONAL MUSIC FRATERNITY
Change of
Address and Information Form
We are interested in knowing about YOU -- where you are, your
professional work, awards, honors and other activities. Please send us
information about yourself on this form.
Please send any change of address information to:
Julie Hensley, Exec Sec. 718 East Ellis St., Suite 3,
Jefferson City, TN 37760 FAX: (865) 475-9716
Email:
DOExecSec@aol.com
Date: _____________________
Name: (First)____________________(Maiden/Middle)__________________(Last)________________________
Current
Address: Street/Apt#
___________________________________________________________________
City,
State, Zip
______________________________________________________________________________
Telephone
Number: (_____)_____________________
Email: ________________________________________
Former
Address: (Street/Apt #)
_________________________________________________________________
City,
State, Zip
______________________________________________________________________________
Chapter
into which you were initiated________________________________________
Date:________________
Are you currently a member of:
Collegiate Chapter? yes______ no______
Name of Chapter_____________________________
Alumni Chapter?
yes______ no______ Name of
Chapter_____________________________
Alumni Club?
yes______ no______ Name of
Club________________________________
If no, are you interested in joining an
Alumni chapter/club? yes_______ no_________
Please list your recent professional
activities, work related information, honors, awards, and other information.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
For additional space, continue on back of
page.
THANK YOU!