JPIA MEMBERSHIP APPLICATION FORM

Local Chapter: Course: ___________________ Year Level: _____ Section:

__________

1st year 4th year 5th year JPIA No.:_____N/A_________

Name: ___________________________________________________________
(Surname) (First Name) (Middle Name)
Current Address: ____________________________________________________
Permanent Address: _________________________________________________
E-mail Address: ________________________ Mobile No.: __________________
Birth date (mm/dd/yy): __________ Age: _____ Sex: ___ Nationality:_________
Person to contact in case of emergency
Name: _______________________Relationship: ____________________
Contact No.: ___________________

Most significant individual award/s (high school and college)

Institution/ Organization/ Person who Name of the award /

Date received
conferred the award / recognition recognition

SELECT

GROUP / TEAM THAT YOU WANT TO BECOME PART OF

JPIA Quizzers’ Pool JPIAn Artists JPIA Tutorials Guild

1. What do you expect from JPIA this federation year?

____________________________________________________________________

____________________________________________________________________

2. What event/s are you looking forward to attend to?

____________________________________________________________________

___________________________________________________________________

3. What can you suggest for JPIA to improve its events / activities for its members?

____________________________________________________________________

___________________________________________________________________

I, hereby, state that the above information are true and correct, that I possess all the qualifications of
being a member of NFJPIA, NFJPIA-R3 and Tarlac State University - JPIA, I will not violate any
rules set for the organization and that I dedicate myself into fulfilling the mission, vision, goals and
objectives of NFJPIA, NFJPIA-R3 and TSU-JPIA.

_____________________________
Signature over printed name