*Chapter/Colony Name:

— PLEASE SELECT ONE — Michigan Stanford Kansas Nebraska California Ohio State Dartmouth Harvard Illinois Franklin Minnesota Wisconsin Missouri Cornell Purdue Chicago Yale Columbia Iowa State Iowa Penn State Oregon Washington Northwestern Colorado Syracuse Kansas State Texas Oklahoma Indiana George Washington North Carolina Oklahoma State Carnegie Tech Oregon State Denver Cincinnati Washington State Southern California Wyoming UCLA Ohio Miami of Ohio Rensselaer New Hampshire Colorado State Evansville Vermont Arizona Arkansas Long Beach State Louisiana State University of Northern Colorado Illinois Wesleyan Central Missouri State Missouri School of Mines Mississippi State Luther A. Smith Memphis State Boston University Central Oklahoma Shippensburg San Jose State Alabama Georgia Tennessee Tri-State Houston Northeast Louisiana East Texas State Emporia State Kearney State College Illinois State University Eastern Illinois Northeastern Oklahoma State Pittsburgh/Johnstown Upper Iowa Stephen F. Austin Nebraska at Omaha Saint Cloud State Cal Poly/Pomona University of Western Ontario California University of Pennsylvania Millersville Carleton Central Florida Johns Hopkins Bloomsburg State University Indiana University of Pennsylvania Morningside College Penn State/Altoona East Stroudsburg Northwestern Oklahoma State University East Stroudsburg Colony Angelo State Colony Lock Haven Colony North Dakota Colony Nicholls State Colony Grand Valley State Colony Texas A&M Colony Toronto Colony

*Chapter Roll No. (PIN):

*Name:

*Address:

*City:

*State/Territory: AK — Alaska AL — Alabama AR — Arkansas AZ — Arizona CA — California CO — Colorado CT — Connecticut DC — District of Columbia DE — Delaware FL — Florida GA — Georgia GU — Guam HI — Hawaii IA — Iowa ID — Idaho IL — Illinois IN — Indiana KS — Kansas KY — Kentucky LA — Louisiana MA — Massachusetts MD — Maryland ME — Maine MI — Michigan MN — Minnesota MO — Missouri MS — Mississippi MT — Montana NC — North Carolina ND — North Dakota NE — Nebraska NH — New Hampshire NJ — New Jersey NM — New Mexico NV — Nevada NY — New York OH — Ohio OK — Oklahoma OR — Oregon PA — Pennsylvania PR — Puerto Rico RI — Rhode Island SC — South Carolina SD — South Dakota TN — Tennessee TX — Texas UT — Utah VA — Virginia VI — Virgin Islands VT — Vermont WA — Washington WI — Wisconsin WV — West Virginia WY — Wyoming CANADA

*Postal Code:

Home Phone with Area Code:

Daytime Phone with Area Code:

*e-mail Address:

Job Title:

Company:

Industry: — Please Select One — Advertising / Marketing / Public Relations Banking / Finance Chemical Construction Education Energy Entertainment Executive Management Food & Beverage Government Legal Manufacturing Medical / Healthcare Pharmaceutical Real Estate Retail Entrepreneur / Self-Employed Social Services Transportation Other

Promotion?     Yes      No

New Job?     Yes      No

What else is happening with you career-wise?

The Fraternity is looking for volunteers to work with chapters and Headquarters on a groundbreaking new initiative - Cornerstones. The mission of Cornerstones is to aid the individual member and strengthen the chapter.

For more information on how you can get involved at the chapter level, select which items interest you from the list below (you can pick more than one). One of our staff members will get in touch with you and help you connect with the right brothers at the chapter level. Remember, you don't have to be an alumnus of a specific chapter to be involved — you don't even have to live in a nearby city. The Fraternity is developing new tools and guidelines to assist our alumni with updated mentoring opportunities such as the following:

Cornerstones Level Advisor — Level Advisors serve as a liaison between International Headquarters and individual undergraduates in facilitating completion of the various levels of the program. You will work via the web, eMail, phone, and in person from time to time. These alumni members will serve an important role in examining the relevance and efficiency of the program. This new role will expand the alumni support base for our undergraduates, which will also benefit the alumni that currently serve in volunteer positions with the chapters.

Career Development Mentor — Career Development Mentors (CDM) are paired with undergraduate brothers who share a chosen professional field. Mentors offer career guidance, and when possible facilitate internships or offer references for new graduates. The goal is to help young brothers build their professional networking skills and offer them a chance to understand their chosen profession from an experienced professional who also shares their history with Acacia Fraternity. It is reasonable to expect that, through career guidance, the CDMs will develop a more personal relationship with the undergraduates as well.

I Got Engaged     I Got Married     I Got Divorced

Fiancé or Wife's Name:

I'm A New Dad     It's A Boy     It's A Girl

New Child's Name:

Child's Name: Age:

Child's Name: Age:

Child's Name: Age:

Child's Name: Age:

What else is happening with you family-wise?