Member Information Form

Theta Xi Nu

Brothers, Please complete this form in order for us to have up-to-date information for the Brotherhood.

"*" indicates required fields

1- Full Name*

2- Control Number*

If you don't know your control number, respond with NEED ASSISTANCE

3- Life Member Number

4- District Life Member Number

5- Line Name

Your line name; not the name of your whole line

6- Line Number

7- Initiation Date

Example: January 7, 2019

8- Chapter of Initiation*

9- Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

10- Cell Phone*

(XXX) XXX-XXXX

11- Email*

12- Date of Birth*

If you do not wish to disclose the year, please enter this year as the year.

13- Employer

14- Industry

15- Job Title

16- Marital Status*

Mark only one.

17- Wife's Name

18- Wife's Birthdate

If you do not wish to disclose age, please enter N/A

19- Wedding Anniversary

Opt-In*

Mark only one.