Text Box: 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., 910 Church Street, 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!


 

 

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