Date of Application:

Complete Name:

Your email

Primary Phone:

Alternate Phone:

Complete Address (Street, City, State and Zip Code)

Date of Birth:

Place of Birth (City and State)

Educational Information:

University/College Degree(s)

Institution(s) Attended:

Institution(s) Attended:

Major of Study:

Cumulative GPA:

Name of the Institution:

Degree Type Sought: (e.g. B.S. or M. Ed.)

Major of Study:

Minor (if any):

Number of hours Completed:

Year of expected Graduation:

Career Objective:

Military Background:
YesNo

If Yes, please explain below:

Private Information:

Are you currently employed?
YesNo

Employer:

Title:

Hobbies:

Organizational Affiliations: (Professional, social, non-fraternal, service-oriented or Masonic)

Leadership Positions: (Describe any leadership roles held/ position)

Private Information Share with the BOC Executive Board Only:

Do you have any health or physical limitations?
YesNo

If Yes, please explain below:

Have you ever been convicted of a crime:
YesNo

If Yes, please explain below:

Reference One:

Complete Name:

Relationship:

Your email

Phone Number:

Complete Address (Street, City, State and Zip Code)

Reference Two:

Complete Name:

Relationship:

Your email

Phone Number:

Complete Address (Street, City, State and Zip Code)

Statement of Intent:
In one page, tell us your objective in joining the Brothers on Campus. As an active member, how can you best serve the needs of the organization? What is your personal philosophy of service to the community?
Mailing Address:
Brothers On Campus
2100 Southbridge Parkway
Suite 600
Birmingham,Alabama 35209

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