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FORM 9A
REPLACES 9A, 9B AND 12;

PREVIOUS EDITIONS

ARE OBSOLETE

REVISED 03/2006
Founders: Frank Coleman, Oscar J. Cooper, Ernest E. Just. Edgar A. Love (Deceased)

OMEGA PSI PHI FRATERNITY, INC.
INTERNATIONAL HEADQUARTERS

3951 Snapfinger Parkway, Decatur, Georgia 30035
APPLICATION FOR MEMBERSHIP



1. Read all instructions and questions before you start

2. Please SEPARATE AND TYPE answers to all questions. Re-staple when completed.

3. After you have completed this application, check to make sure you have answered all questions.

4. Be sure to sign your completed application in BOTH sections of Part IV.
FOR OFFICE USE ONLY DO NOT WRITE BELOW THIS LINE

_______________________________________________________________________________________



_____________ Approved or Disapproved ______________

Applicant’s Full Name ________________________________________________________________________________________________

First Middle Last Suffix


Control/Membership No. _____________________________ Date of Birth __________________________ DOD _________________


Street Address _______________________________________________________________________________________________________



City ______________________________________________ State _________________________________ Zip Code ________________
Telephone _________________________________________ Chapter _______________________________ DOI ___________________

Friendship is Essential to the Soul Ωφελημα Ψυχι Φιλια

~ APPLICATION FOR ADMISSION TO MEMBERSHIP



OMEGA PSI PHI FRATERNITY, INC.

PLEASE TYPE

PART I. PERSONAL INFORMATION:
Applicant’s Full Name ________________________________________________________________________________________________________________

(First) (Middle) (Last) (Suffix)


Permanent Home Address _____________________________________________________________________________________________________________
City ________________________________________________________ State _________________________ Zip ______________________________
Residence Telephone __________________________________________ School or Office Telephone ______________________________________

Present Address (if different from above) _______________________________________________________________________________________________________________

City __________________________________________________________ State ______________________________ Zip ________________________________

Date of Birth ____________________________________ Marital Status ______________________________ Number of Children ____________________


If yes, list dates you Applied

Have you ever applied to: A. Omega Psi Phi? Yes No

B. Other Fraternity? Yes No
Are you currently employed? _________________ If yes, Occupation; (use Codes on last page) __________________________________________ Undergraduate students enter 00

□ Part –Time □ Full –Time Place of Employment: _____________ ____________________________________________________________________ _______________-


Father’s Full Name ___________________________________________________________ Is he living? ______________________________________


Father’s Occupation (use Code # on last page) __________________________________________________________________________
Mother’s Full Name __________________________________________________________________ Is she living? ________________________________
Mother’s Occupation (use Code # on last page) ___________________________________________________________________________________________
Number of Brothers ___________________ Ages ____________________ Number of sisters ___________________ Ages ___________________
Number of Dependents (Spouse/Children) _______________________________ Ages ___________________________________________________
Number of brothers/sisters in college __________________________________
Name other members of your family who belong to a fraternity or sorority. Specify their relationship to you and list organizations to which they belong.


Name Relationship Organization


___________________________________________________________________________________________________________________________________________________________________________________________________


Ωφελημα Ψυχι Φιλια

Friendship is Essential to the Soul

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PART II. ACADEMIC INFORMATION

Academic classification: □FR □SO □JR □SR □Post-Baccalaureate □Grad. Student □ Other

Specify Other ______ _____ _______________________

Grade point average in undergraduate college? _________________________________________________________ (on a 4.0 system)


UNDERGRADUATE COLLEGES ATTENDED

(List in chronological order all undergraduate colleges you have attended or are currently attending. Include summer sessions.)


Institution/Location Dates of Attendance Major (See codes last page) Degree and Date Conferred or

expected (Month and Year)

_______________________________ _____________________ ________________________ _____________________________


_______________________________ _____________________ ________________________ _____________________________
_______________________________ _____________________ ________________________ _____________________________
_______________________________ _____________________ ________________________ _____________________________
_______________________________ _____________________ ________________________ _____________________________


GRADUATE/PROFESSIONAL SCHOOLS ATTENDED

(List in chronological order all undergraduate colleges you have attended or are currently attending. Include summer sessions.


Institution/Location Dates of Attendance Major (See codes last page) Degree and Date Conferred or

expected (Month and Year)
_______________________________ _____________________ ________________________ _____________________________
_______________________________ _____________________ ________________________ _____________________________
_______________________________ _____________________ ________________________ _____________________________
_______________________________ _____________________ ________________________ _____________________________
_______________________________ _____________________ ________________________ _____________________________

Note: Official transcript(s) bearing the university seal must be sent directly to the District Representative. Undergraduates must also have a certification form sent attesting to enrollment as a full-time student.

Ωφελημα Ψυχι Φιλια

Friendship is Essential to the Soul

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PART III. BIOGRAPHICAL INFORMATION
1. How did you first learn about Omega Psi Phi Fraternity? Be as specific as you can be.

2. Describe jobs or positions of responsibility that you have held. If you have had experience in community service, what contributions have you made? Include dates and leadership positions held.

3. Give names and complete addresses of 3 individuals who have written reference letters for you.
_________________________________________________________ _________________________________________________________ _________________________________________________________

4. Extra-curricular activities: Describe and comment on hobbies, recreational activities and other uses of your time. Name significant positions you held in college.


_________________________________________________________ _________________________________________________________ _________________________________________________________

_________________________________________________________ _________________________________________________________ _________________________________________________________

Ωφελημα Ψυχι Φιλια

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5. In 200-250 words, state your purpose for applying at this time. Indicate how you perceived the fraternity can assist you in achieving your career goals. In the process, please provide details on your background and motivations. Your response may not exceed and must be typed in the space provided below. (You may adjust the font to an appropriate size.)

Ωφελημα Ψυχι Φιλια



Friendship is Essential to the Soul

Page 5 of 23

6. Write a 500 word essay about a famous Omega Man. Your response may not exceed and must be typed in the space provided below. (You may adjust the font to an appropriate size.)

Ωφελημα Ψυχι Φιλια

Friendship is Essential to the Soul

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FORM 9A

Attachment 1

Revised 07/05

PART IV A. CERTIFICATION

Name (Print) _________________________________________________________________________________________________________


Address ____________________________________________________________________________________________________________
I understand that withholding information requested on this form or knowingly giving false information may make me ineligible for admission to Omega Psi Phi Fraternity, Inc. or subject to dismissal, if determined after I become a member. I certify that the statements I have made on this application are correct and complete to the best of my knowledge, information and belief.
AS A CONDITION OF MY PARTICIPATION TN THE OMEGA PSI PHI FRATERNITY, INC.’S MEMBERSHIP INTAKE, I DO HEREBY ENTER IN THE FOLLOWING STIPULATIONS. COVENANTS AND AGREEMENTS:
I certify that I am aware of the fact that Omega Psi Phi Fraternity, Inc. expressly prohibits and vehemently opposes the use of physical or mental harassment/hazing in any of its activities. I understand that hazing includes but is not limited to physical violence such as paddling, slapping. pushing of my body by of any object, device or hand; strenuous exercise, forced inducement or the causing of me to consume any food, liquid or other substance, pouring sprinkling or covering of my body with airy substance; threatening or causing me to be placed in fear of receiving any physical injury such as the activities listed above and generally any act or acts which would tend to cause any person any humiliation, embarrassment or physical harm. I agree that I shall never permit any acts of hazing, whether they be physical or mental, to be used against me before, during or after The Membership Intake Program. I further agree to report any acts of hazing or attempted hazing promptly to the Regional Intake Team in writing with a copy to the District Representative. I understand that no punitive action will be taken against me for rendering said report. Further, I understand that failure to render said report shall serve as sufficient cause for my dismissal from the intake program or from the Fraternity if admitted. Additionally, I have been informed that I am entitled to receive a listing of the fees associated with admission to membership in the Fraternity and a copy of the roster which lists the financial members of the Chapter. I understand that only the members of the Regional members of the Regional Intake Team are permitted to he involved with me and my activities as a prospective for membership.
I understand that the Omega Psi Phi Fraternity, Inc is a non-profit corporation, having Its domicile and principal place of business in Washington. District of Columbia. I hereby stipulate and agree that any and all lawsuits other than claims that I may have arising out of my participation in the Omega Psi Phi Fraternity, Inc. Membership Intake Program shall be governed by the laws of the District of Columbia and that such lawsuits and claims shall be brought, filed sued upon solely within the jurisdiction of the courts of the District of Columbia.
I certify that I have read this document thoroughly and understand same; that I agree to and do bind myself to all of the terms and conditions contained herein. Accordingly. I do hereby release the Omega Psi Phi Fraternity, Inc. and do hold same harmless, as well as its insurers, employees, agents, successors and assigns from any and all liabilities for damages incurred by me as a result of my participation in its Membership Intake Program. I further bind my legal representatives, heirs, successors and assigns to the terms and conditions of this agreement.
I agree that, should any part of this agreement be found to be illegal for any reason, the illegal part or parts shall he severed hencefrom and the remaining agreements and stipulations shall be given full force and effort as if those severed did not exist.
I certify that I am at least eighteen years of age, or that lam the parent or legal guardian of the applicant herein and do exercise this document on his behalf. Further, I certify that I enter into these stipulations and agreements knowingly, freely and without duress or coercion of any kind.

Witness my hand and seal this _________ day of _____________________, 20____, city/state ________________________________________________

__________________________________________________________ ________________________________________________________

Applicant Name (Print) Notary Public’ Signature

__________________________________________________________ ________________________________________________________

Signature: Applicant/Parent/Legal Guardian Commission expires (Date)

_______________________________________________________

Seal


Ωφελημα Ψυχι Φιλια

Friendship is Essential to the Soul

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Form 9A-20

OMEGA PSI Pill FRATERNITY, INC.

ACKNOWLEDGEMENT AND INDEMNIFICATION AGREEMENT
Name of Applicant or Member (Print) _____________________________________________________________________________________________________________________________________
Social Security Number (Applicant) _______________________________________________________________________________________________________________________________________
Street Address _____________________________________________________________________________________________________________________
City/State/Zip Code __________________________________________________________________________________________________________________
Chapter Name _______________________________________ CHAPTER LOCATION ______________________________________________________

I certify that I am aware of the fact that Omega Psi Phi Fraternity, Inc. expressly prohibits and vehemently opposes the use of physical or mental harassment/hazing in any of its activities. I understand that hazing includes, but is not limited to, physical violence such as paddling, slapping, pushing of another’s body, by use of any object, device or hand; strenuous exercises; forced inducement or the causing of another to consume any food, liquid or other substance; pouring, sprinkling or covering of another’s body with any substance; threatening or causing another to be placed in fear of receiving any physical injury such as the activities listed above and generally, any act or acts which would cause any person any humiliation, embarrassment or physical harm.


I agree that I shall report any acts of hazing or attempted hazing promptly to the Membership Selection Team in writing with a copy to the District Representative, or directly to the District Representatives. I understand that failure to render said report shall serve as sufficient cause for my dismissal from the Fraternity.
I understand that the Omega Psi Phi Fraternity, Inc is a non-profit corporation, incorporated in the District of Columbia, and having its domicile and principal place of business in Decatur, Georgia.
I understand that the only agents of the Fraternity are the Supreme Council and/or the Brand Conclave, who may from time to time, employ persons or firms to act on behalf of the Fraternity. I understand that, as member or potential member of Omega Psi Phi Fraternity, Inc., I am not an agent of the organization. Further, I understand that I have no authority whatsoever to enter into any agreements, whether oral or written that would obligate Omega Psi Phi Fraternity, Inc. in any way.
I certify that I have read this document thoroughly and understand same; that I agree to and do bind myself to all of the terms and conditions contained herein. Accordingly, I do hereby release and indemnify the Omega Psi Phi Fraternity, Inc. against any claim, loss, damage, or expense caused by me for actions which subject the Fraternity’s assets to judgments for losses, damages or expenses awarded by a court or agreed upon in settlement negotiations. I further bind my legal representatives, heirs, successors and assigns to the terms and conditions of this agreement.
I certify that I am at least twenty-one (21) years of age or that I am the parent or legal guardian of the undersigned and do exercise this document on his behalf. Further, I certify that I enter into these stipulations and agreements knowingly, freely and without duress or coercion of any kind. I further certify that my date of birth is _______________________________________________________________________________________________________________________
Witness my hand this __________________________ day of , 20____, city/state ___________________________________
_______________________________________________ ______________________________________________________

Signature: Applicant or Member Signature: Notary Public


________________________________________________ _______________________________________________________

Signature: Parent/Legal Guardian if member Commission expires (Date)

Is under 21 years of age
Parent’s Address __________________________________ Seal
_________________________________________________

Ωφελημα Ψυχι Φιλια



Friendship is Essential to the Soul

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FORM 9A Attachment 2-1

Revised 03/06
OMEGA PSI PHI FRATERNITY, INC.

AUTHORIZATION TO RELEASE INFORMATION FORM

Printed Name: ________________________________________________________________________________________________________

Last First Middle

Date of Birth ____________________________ Social Security # _______________________________________

Home Phone Number ___________________________ Business Phone # _______________________________

Other Names You Have Used ______________________________________________________________________


Current Address:

_______________________________________________________________________________________________

Street Number and Name City State Zip How Long?

Have you been background checked by Omega Psi Phi Fraternity previously? YES □NO
If yes, please note date (approximate): ____________________________________________________________________________________
HAVE YOU BEEN COVICTED OF FELONY, MISDEMEANOR CONVICTION, OR OTHER CRIME, BY ANY COURT YOU MAY OMIT? MINOR TRAFFIC VIOLATIONS FOR WHICH THE FINE IMPOSED WAS $400.00 OR LESS. □YES □NO
If yes, please indicate date, location and explanation
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HAVE YOU BEEN CONVICTED OF A CRIME UNDER ANOTHER NAME? □YES □NO

IF YES, STATE NAME: ______________________________________________________________________________________________________________
Complete driver’s license information.

DRIVER’S LICENSE INFORMATION: _________________________________________________________________________________________________

License number Expiration Date State of Issue

Notice



The principal purpose for requesting the information on this form is to conduct background checks on individuals petitioning for membership in Omega Psi Phi Fraternity, Inc.

Furnishing all information requested on this form is mandatory. Failure to provide such information shall result in a determination that the applicant is ineligible for membership or not appropriate for consideration.

I hereby aggress to permanently waive and forego any rights or causes of action I may have against Omega Psi Phi, and its agents, officers or assigns as a result of the use, release or dissemination of the collected information and shall indemnify and hold harmless the Fraternity, its chapters, Districts, officers, assigns, or successors in interest from any and all liability that may result from the use, release or dissemination of the collected information.

I hereby certify that all statements on this application are true and correct to the best of my knowledge and belief. I understand that Omega Psi Phi Fraternity, Inc. solicits this information so as to be informed of my previous record and character. I understand that consideration of my membership application depends upon successful completion of a background investigation. If granted membership, I understand that any falsification, misrepresentation or omission of facts of this record may be considered cause for expulsion.

Applicant Signature ___________________________________________ Date ___________________________________
FORM 9A

Attachment 2-2

Revised 03/06
OMEGA PSI PHI FRATERNITY, INC.

FURTHER AUTHORIZATION FOR BACKGROUND CHECK
I understand that in evaluating my application for potential membership and thereafter to evaluate my continued suitability or fitness for membership, OMEGA PSI PHI FRATERNITY, INC. may from time to time procure or have prepared an employment, education, criminal history, motor vehicle, military and/or investigative report about me. I consent to and hereby authorize OMEGA PSI PHI FRATERNITY, INC. to obtain these reports, and by copy of this authorization, I have been notified that the above stated reports may be requested.
I also authorize OMEGA PSI PHI FRATERNITY, INC. to procure records or other information about my background, character, general reputation, driving record, military service, and/or employment performance in connection with my application for membership and from time to time thereafter in connection with my membership. I authorize all persons, schools, employers, companies, corporations, law enforcement agencies and other government agencies to release documents or other information to OMEGA PSI PHI FRATERNITY, INC. and to any company hired by it. This authorization includes matters of opinion relating to character, ability, reputation and past performance.
If I am offered membership prior to the completion of any of the reports, I realize that my continued participation is contingent upon favorable results of such reports. If unfavorable information is developed, I realize my membership participation is subject to termination.
Name _________________________________________________________________________________________________________________________________________________________________________________________________________
DOB____________________________________________________________________SSN:________________________________________
Current Address _____________________________________________________________________________________________________________________
Driver’s License No.: State:_____________________________________________________________
Signature ___________________________________________________________________________________________________________________________

If you have a previous address or address within the last tive years, please list below:

Previous address or addresses within the last five years:
1.
Street: _____________________________________________________________________________________________________________________________

City, State, Zip: ____________________________________________________________________________________________________________________________________________________________________________________________


2.

Street: ____________________________________________________________________________________________________________________________



City, State, Zip: _____________________________________________________________________________________________________________________

Ωφελημα Ψυχι Φιλια

Friendship is Essential to the Soul

Page 10 of23

FORM 9A



Attachment 2-3

Revised 03/06
OMEGA PSI PHI FRATERNITY, INC.

FURTHER AUTHORIZATION FOR BACKGROUND CHECK (CONT’D)

3.
Street: _____________________________________________________________________________________________________________________________
City. State. Zip: _____________________________________________________________________________________________________________________


4.
Street: _____________________________________________________________________________________________________________________________
City, State, Zip: _____________________________________________________________________________________________________________________

5.
Street: ____________________________________________________________________________________________________________________________

City, State, Zip: _____________________________________________________________________________________________

If you are under the age of 2l, your parent/guardian must sign this form.

_______________________________________ _________________________________________

(Candidate’s Signature) Date:


_______________________________________ ________________________________________

(Print Witness or Notary’s Name) (Witness or Notary’s Signature)


_______________________________________ ________________________________________

(Print Parent/Guardian Name) (Parent/Guardian Signature)


Ωφελημα Ψυχι Φιλια



Friendship is Essential to the Soul

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FORM 9A

Attachment 2

Revised 07/05

AUTHORITY FOR RELEASE OF INFOMRMATION -
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