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
Page 2 of 23
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
Page 3 of 23
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
Friendship is Essential to the Soul
Page 4 of 23
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
Page 6 of 23

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
Page 7 of 23

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  
Page 8 of 23

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
Page 11 of 23
FORM 9A
Attachment 2
Revised 07/05

AUTHORITY FOR RELEASE OF INFOMRMATION - PART II

Name	Social Security #	FOR OFFICE USE ONLY	
YOUR MILITARY RECORD
Have you ever received other than an honorable discharge from the military? If yes please provide:	YES	NO	
Date of Discharge (Month and Year)	Type of Discharge:	
Have you ever been subject to court-martial or other disciplinary proceedings under the Uniform Code of Military Justice? If  “Yes,” list any disciplinary proceeding in the last 15 years and all court-martials.	YES	NO	
Date (Month/Year_	Charge or Specification	Place (City and county/country if Outside the U.S.	
YOUR EMPLOYMENT RECORD	
Has any of the following happened to you in the last 15 years?  If “Yes” begin with the most recent occurrence and go backwards, providing date fired, quit, or left, and other information requested.	YES	NO	
Use the following codes to explain the reason your employment ended:
1 – Fired from Job                                    3 – Left a job by agreement following allegations of misconduct         5 – Left a job for other reasons under  unfavorable 
2 – Quit a job after being told
       you’d be fired                                    4 – Left a job by mutual agreement following allegations of                      circumstances
                                                                        unsatisfactory performance	
Date (Month/Year)	Code	Employer’s Name & Address	State	Zip Code	
YOUR POLICE RECORD	
If you answer “Yes” to a, b, c, d  or e below, explain your answer(s) in the space provided. Do not include anything that happened before your 16th birthday	
a.   Have you ever been arrested, charged, or convicted of a felony offense?	YES	NO	
b.   Have you ever been  arrested, charged, or convicted of a firearms or explosives charge?	YES	NO	
c.   Are there currently any charges pending against you for any criminal offense?	YES	NO	
d.   Have you ever been arrested, charged, or convicted of a felony offense related to alcohol or drugs?	YES	NO	
a.   Have you ever been arrested, charged, or convicted of any type of offense? Leave out traffic fines of less than $100.	YES	NO	
Date (Month/Year)	Offense	Action Taken	Law Enforcement Authority or Court (City and County/Country if outside the U.S.)	State	Zip	

						
						
YOUR INVOLVEMENT WITH ALCOHOL AND DANGEROUS DRUGS INCLUDING MARIJUANA AND COCAINE	
This item concerns the use of alcoholic beverages, and the supplying or using, without a prescription, of marijuana, cocaine, hashish narcotics (opium, morphine, codeine, heroin, etc.), stimulants (cocaine, amphetamines, etc.), depressants (barbiturates, methaqualone, tranquilizers, etc.) hallucinogenics (LSD, PCP, or other dangerous or illegal drugs?	YES	NO	
a. Do you now use or within the last 5 years have you used alcoholic beverages habitually to excess?			
b. Do you now use or within the last 5 years have you used or supplied, marijuana, cocaine, narcotics, hallucinogenics or other dangerous or illegal drugs?			
c. If you answered “Yes” to questions a or b above, provide information below relating to the types of substance(s) used, the periods of frequency of use for dangerous or illegal drugs?	
From (Month/Year)	To (Month/Year)	Type of Substance	Explanation (in your comments be sure to give the frequency of your use during each period you listed, including the period of most recent use)	

CODE SHEET

COLLEGE MAJOR CODES
Ott No Maior Undecided	22 Cts’tl Enginecrisg	43 History’	64. Natural Sciences	83 Pre.nentistO
SI Accounting	23 Classics	44 Health Education	65. Neuroscience	04 Psychobiology
02 Admtn,straos,n Supervision	24 (‘omntur,,eatians	45 I ii,mc Econo,nics	Sb. Nursing	85 Psychi,Iogv
(IS Aerepace Engineering	25 Coinpoter Science, Data Processing	46 Horinrs Prttpeorn	67 Notrttion	66 thuhltc Health
04 Agneulttu’e Agtonoiny	26 Correertons/Cnminal Justice	47 Hospital Administration	56. Occupational Therapy	67 Radiology]
03 Attatone	27 Dentistry	45 Hotel/Motel Manageinoni	69. Oceanography	110 Recreation
06 Art(rcopologv	20 nesign	48 iinrna~itiies	70 llpuooetrv	69 Religioiilfheolegy
(17 Architectute	29 Dnaano	50 interdisciplinary Stndies	71. Osteopathy	90 Science-General
OS Art	30 Ecoooneics/F,nancr	SI Journahsm	72 Pathology	SI Sociai Work
00 Autrononty	3! F.dncatiott’Elernotitarv Sc~cc~ttdory	52 toss’	73 Percent, el	92 Sociolsig
Ill Biecheiniutri	32 Education . Higher	33 liberal Arts	74 Pliartnaeologo	93 Speech,Ao,hii logy
II Hsilogy	33 Engitreering (Not Cic,11	94 library Science	73. Phornacs	94 Statistics
12 i4io,nrdcul Ergireci ing	$4 English	55 Lingnistics/l.tteratnre	75, T’Iiiiosophy	95 Theatre Arts
13 Bioosedteal Science	$5 Envitotoocotal 5ttidicn	Sb Marketing	77, Physical Therapy	96 Urban Stadies
14 Biophysics	35 Film	57 Mathematics	75 Physics	97 Veterinary Medmemne
(5 Black Smodtes’Ethnic Siudie,s	37 Food and Nuti tttonlflietetmcs	58 Medicoic	79. Physiology	90 Zoology
It Botany	30 Foeeigmt Langaage(sI	50 Medical i’echnokigy	0(1 Pirltticel Sciet,ce
17 Broadcasting	39 Genetics	6)) Meteorology	Oh Pre-Mndicinr
IS Business Conmierce	40 tieogeaplmy	SI Microbiology br Bactcrtologyl
I 9 Business Administratioit	41 Geology	62 Military Scicitcc
21) chemistry	42 Guidance Cooncuhug	53 Motic
21 kinorna

OCCUPATIONAL CODES
00 Full Ttme-Untlcrgraduatc 5ttideitt	21 (‘timpater Fersonttch	42 Hnn,emaher/Fionsewite	64 Paintei ‘PaperhaagorPlsstorer	00 Sales Persoim. Broker
(II AecnntttlBiniklseeprn	22 Cock ‘BaLe,	43 Hoosekeepen/Domeutic Wt,ekcr	65 Pharmacist	SI Secretary-St ettographer
02 Adjuster/Appraiser	23 (‘onnseli,i/l’ersantrel Worker	44 inspector	66 Photographon/Phtilographie Industry	82 Service Teohiticiat,
03 Admninisteatttr	24 Csstodta,s,50nitation Worker	45 ironworker	67 Physician	63 Scientist (Natural Physical)
04 Agriculture Industry Worker	2$ t.teniiut	46 Jeweler Jewelry Industry	65 PluniberiPipe litre,	64 Scentint ISoetal IPolilicol)
(15 AircrafilAtnlinelMtsstlc.’	26 Dcsigmmcr	47 JudgeiMagistrate	69 Podiatrist	83 Ss,etal Vi’orkci
  Spacecraft lndustrs’	27 Dietitian	48 l.aboeutto3t Wm,rkor	70 P,irlal Service Employee	06 Speech Paihm,lmmgisl and Audiologist
(lb l.’Iothing Industry	NI Drivrr I I’raek/i9ns.Cahl	49 Laborer	71 Prinriog/l’uhlishing Im,dosrrv Pen,o,i,rrl	57 Sarsry,ir
07 Arishitect	28 EeonontintfFtnancter	50 Laundry ond Dry Cleaning	72 Psychologist	OS Toilor.’Seanistress
08 ,Attendantikmde/’sssistaot	30 Lnginccr	   industry/Personnel	73 Publmc Relations Personnel	89 Tcacltcr ‘Edocator.
(19 Attorney	SI Electrician	SI i,aw Enforcement 0 (Seer	74 Radmo’Tclevmsioit Niottor, Pictunc industry	Profc’nstir/insteucttir
II) Aototnabtle Sales art) Service	32 F’rtertaoter/Artist,Masiciait	52 Librarian	75 Receptionist	911 ‘IechnicianTechnologist
II Barber	~13 Fstertniitator	53 Lacksittith	76 Recreatinit/Letsoce Winker	ill ‘rhnra1tist
12 Bat’tender	34 Ftrefmgbtter	54 Moclitumet	77 Reps irnton	92 b,ndet writer
13 BricklayeelStonetnason.’Cetucnt	35 Florisi,’Florol Worker	55 Manager	76 Rescrvationificket/Passengee.TraVeI Agent	93 Urban P loaner
   Mason	36 Fimod Service Wt,rhcr	Sb Mathcmsmtician/Stutislicion	75 Retired	94 Upholsteret
14 Busitmessrnoa Entrcprcmtonr	37 Faneral DircctorMortteiott	57 Mechaitic		95 Voterinariais
IS Butcher/Meat Cttitrri Meat	   Emhal,ner	38 Meier		96 95 otter Waitress
   ‘ocher	38 Glazier	39 Militoi’s’ Pzro,,nnel		9/ Wrldet ‘Sheet Metal Worhee
16 Bayer/Parchantng Agent	39 Goscmnient Employee	611 Minister Clergyition		98 WriicriAnthnr/RepnnteelJanrnalist
17 Carpenter	40 Health Care Wsirkcr	1,1 Nunse		9’) Other.Not L,sied Above
IS Ca.shiori’eilcr	41 i ltstsiriorr	62 Operant,
19 (.‘hirirpracitrr		1,3 1 )ptttmeirist
20 (‘bork/L’laoeal Wo,ker

Omega Psi Phi Fraternity, Inc.
3951 Snapfinger Parkway
Decatur, Georgia 30035

 

Ωφελημα Ψυχι Φιλια
Friendship is Essential to the Soul
Page 13 of 23

FORM 9A Attachment IF
Revised 03/06

OMEGA PSI PHI FRATERNITY, INC.

Member Code of Conduct
&
Disciplinary Policy

I certify that I have read this document thoroughly and understand same, that I agree and do bind myself to all of the terms and conditions therein.

Name of Applicant or Member ___________________________________________________________________________________________

Social Security Number _________________________________________________________________  DOB  _________________________

Street Address ________________________________________________________________________________________________________

City ____________________________________________    State   _____________________________  	Zip Code __________________________

Signature ___________________________________________________________________________________________________________________________________    Date  _____________________________

Chapter Name ___________________________________________________________________	District ______________________________

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 and I too have read Omega Psi Phi Fraternity, Inc. Member Code of Conduct & Disciplinary Policy.

___________________________________________________________________________
Signature Parent/Legal Guardian if member is under 21 years of age.

Ωφελημα Ψυχι Φιλια
Friendship is Essential to the Soul
Page 14 of 23
FORM 9A
Attachment 1G
Revised 03/06

Omega Psi Phi Fraternity, Inc. 
________District

RELEASE AND WAIVER

I hereby grant to Omega Psi Phi Fraternity, Inc. an exclusive right to use the described photographs or videotaped likeness of me in whatever manner it deems appropriate, whether for identification or other purposes while I am participating in an intake process of Omega Psi Phi Fraternity, Inc. and at any time subsequent thereto. I acknowledge that the pictures may be duplicated and distributed by Omega Psi Phi Fraternity, Inc. in any and all manner and media throughout the world in perpetuity.

I warrant and represent that I will indemnify and hold Omega Psi Phi Fraternity, Inc., its officers, agents and assigns harmless from and against any and all claims, damages, liabilities, cost and expenses arising out of a breach of the foregoing warranty.

Dated this _________________ day of  ______________________________, _____________________________

		Name: _______________________________
		
		Signature: __________________________________
	(Attach photos here)	
		Driver’s Lic. No._____________________________
		
		Address:____________________________________
		
		____________________________________________

This form should be sent to the International Headquarters as a part of the candidate’s application with two passport sized pictures attached

Ωφελημα Ψυχι Φιλια
Friendship is Essential to the Soul
Page 15 of 23
OMEGA PSI PHI FRATERNITY, INC.
RECOMMENDATION FOR MEMBERSHIP

TO THE APPLICANT: Complete this portion of the form. Then give the form to one of the individuals who will write a recommendation for you. Provide a stamped self-addressed envelope to that individual.  The Chairman of the Regional Membership Intake Team will provide the address to which the recommendation is to be sent when completed.

________________________________________________	_______________________________________
NAME OF APPLICANT	SOCIAL SECURITY NUMBER

TO THE RECOMMENDER: Please answer the following questions concerning the above named applicant.

How long have you known the applicant? (years/months)

Under what circumstances have you known the applicant?

Give specific examples of occasions where the applicant displayed leadership ability. Provide some detail.

Based on your personal knowledge and involvement with the applicant, provide specific examples of his service to the community/and or University.

Provide any other information that you feel will provide additional insight into the following aspects of the applicant’s character:
integrity, maturity and responsibility.

(continue on back of page, if necessary)

_______________________________________________________		_____________________________________________________
Recommender’s  Name (TYPE OR PRINT)				Title/Position	

Signature ______________________________________________________ 		Date _______________________________________________________

Address ____________________________________________________________________________________________________________________________
Tel.# (	) _________________________________________________
Control/Membership#:	_____________________________________________________   Exp Date:  _______________________________

Ωφελημα Ψυχι Φιλια
Friendship is Essential to the Soul
Page 16 of 23

OMEGA PSI PHI FRATERNITY, INC.
RECOMMENDATION FOR MEMBERSHIP

TO THE APPLICANT: Complete this portion of the form. Then give the form to one of the individuals who will write a recommendation form you. Provide a stamped self-addressed envelope to that individual. The Chairman of the Regional Membership Intake Team will provide the address to which the recommendation is to be sent when completed.

________________________________________________________________	_____________________________________
NAME OF APPLICANT	SOCIAL SECURITY NUMBER

TO THE RECOMMENDER: Please answer the following questions concerning the above named applicant.

How long have you known the applicant? (years/months)

Under what circumstances have you known the applicant?

Give specific examples of occasions where the applicant displayed leadership ability. Provide some detail.

Based on your personal knowledge and involvement with the applicant, provide specific examples of his service to the community/and or University.

Provide any other information that you feel will provide additional insight into the following aspects of the applicant’s character:
integrity, maturity and responsibility.

(continue on back of page, if necessary)

_______________________________________________________		_____________________________________________________
Recommender’s  Name (TYPE OR PRINT)				Title/Position	

Signature ______________________________________________________ 		Date _______________________________________________________

Address ____________________________________________________________________________________________________________________________
Tel.# (	) _________________________________________________
Control/Membership#:	_____________________________________________________   Exp Date:  _______________________________

Ωφελημα Ψυχι Φιλια
Friendship is Essential to the Soul
Page 17 of 23
OMEGA PSI PHI FRATERNITY, INC.
RECOMMENDATION FOR MEMBERSHIP

TO THE APPLICANT: Complete this portion of the form. Then give the form to one of the individuals who will write a recommendation for you. Provide a stamped self addressed envelope to that individual. The Chairman of the Regional Membership Intake Team will provide the address to which the recommendation is to be sent when completed.

__________________________________________________________	_____________________________________
NAME OF APPLICANT	SOCIAL SECURITY NUMBER

TO THE RECOMMENDER: Please answer the following questions concerning the above named applicant.

How long have you known the applicant? (years/months)

Under what circumstances have you known the applicant?

Give specific examples of occasions where the applicant displayed leadership ability. Provide some detail.

Based on your personal knowledge and involvement with the applicant, provide specific examples of his service to the community/and or University.

Provide any other information that you feel will provide additional insight into the following aspects of the applicant’s character:
integrity, maturity and responsibility.

(continue on back of page, if necessary)

_______________________________________________________		_____________________________________________________
Recommender’s  Name (TYPE OR PRINT)				Title/Position	

Signature ______________________________________________________ 		Date _______________________________________________________

Address ____________________________________________________________________________________________________________________________
Tel.# (	) _________________________________________________
Control/Membership#:	_____________________________________________________   Exp Date:  _______________________________

Ωφελημα Ψυχι Φιλια
Friendship is Essential to the Soul
Page 18 of 23

FORM IA
OMEGA PSI PHI FRATERNITY, INC.
MEMBERSHIP SELECTION PROCESS
POLYGRAPH WAIVER

Name of Applicant or Member (Print)   _______________________________________________________________

Social Security Number     _________________________________________________________________________

Street Address ___________________________________________________________________________________

City/State/Zip Code  ______________________________________________________________________________

Chapter Name   _____________________________________________		District _______________________

I, __________________________________________ certify that I am at least 21 years of age or that I am the parent or legal guardian of the applicant herein and do execute this document on his behalf. I certify that I enter into this waiver knowingly, freely, and without duress or coercion of any kind.

I certify that I have thoroughly read and understand the Fraternity’s policy on Hazing. 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 hereby agree, for purposes of investigating acts of harassment/hazing, to submit to a lie detector test administered at the request of the District Representative. I understand that the cost of this examination is to be borne by the Fraternity when so requested.

I further agree that as a condition of my participation in the Omega Psi Phi Fraternity, Inc.’s Membership Selection Process as a member or prospective candidate, I do hereby enter into this waiver and stipulation.
WITNESS my hand and seal this  ______________	day of ___________, 20____

(City/State)   ____________________________________________________________________________

_______________________________________________________________________________________________
Prospective Candidate’s or Member’s signature

__________________________________________________________________________
Parent or Legal Guardian if prospective candidate under 21 years old.

___________________________________	________________________________
Notary	Commission Expires (Date)

Ωφελημα Ψυχι Φιλια
Friendship is Essential to the Soul
Page 19 of 23
FORM 89

OMEGA PSI PHI FRATERNITY, INC
Medical Consent Forms and Releases

Name of Applicant:  _____________________________________________________________________________________________________________________________________
			Last					First			Middle Initial

Home Address:  ________________________________________________________________________________________________________________________________________

City:   _____________________________________________________________ 	State:   __________________________________________	Zip Code:   _________________

Sponsoring Chapter/Address:    ____________________________________________________________________________________________________________________________

Responsible Party in Chapter:  ____________________________________________________________________________________________________________________________

Address:  _______________________________________________________________    City:  __________________________   State:  _______________    Zip Code:  ____________

Telephone: Home  (           ) ____________________________________________________________	Business  (        ) ___________________________________________

MEDICAL EXAMINATION

Date of examination  _______________________________________________________	Applicant’s Date of Birth   _______________________

Height  ______________________	Weight  ______________________	Blood Pressure _________________________________________

		NORMAL			ABNORMAL		COMMENTS

Eyes		______________________	______________________	______________________________________________________

Ears		______________________	______________________	______________________________________________________

Nose, Throat  	______________________	______________________	______________________________________________________

Heart, Lungs	______________________	______________________	______________________________________________________

Abdomen		______________________	______________________	______________________________________________________

Extremities	______________________	______________________	______________________________________________________

Neurological	______________________	______________________	______________________________________________________

Allergies to Medicine:		_______________  YES	________________  NO	If yes, please list:   ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Restrictions:  ___________________________________________________________________________________________________________________

Physician’s Name (print)	___________________________________________________________________________________________________
			Address:  ___________________________________________________________________________________________
			City/State/Zip:  ______________________________________________________________________________________
			Phone:   ____________________________________________________________________________________________

Physician’s Signature		___________________________________________________________________________________________________

Parent/Guardian (NAME):    ____________________________________________________________	Phone: H (       )  ___________________________
ADDRESS:   ________________________________________________________________________	             B (        )  __________________________
STATE:         ________________________________________________________________________    ZIP __________________________________________
(*Examination must not have been given more than 90 days prior to activity.  Date (s) of activity is/are _______________________________________________) 

Emergency Contact if parent/guardian not available:
Name:  ___________________________________________________	Address:  ______________________________________________________
State:    ___________________________________________________	Phone H (        ) ____________________  B (       ) _____________________
Name:  ___________________________________________________	Address:  ______________________________________________________
State:    ___________________________________________________	Phone H (        ) ____________________  B (       ) _____________________

Family Doctor:   Name  ___________________________________________________	Phone (         )  ______________________________________________
ADDRESS:      __________________________________________________________	STATE   ___________________  ZIP  ___________________________
Medical Insurance Policy Name  ____________________________________________	Policy #  ___________________________________________________
	To be answered by parent or guardian		(Circle	onel
	DOES	YOUR CHID HAVE OR EVER HAD:
	I.	Sickle Cell Anemia?	NO	YES
	2.	Food medication allergy?	NO	YES
	3.	Epilepsy, seizures, fainting spells?	NO	YES
	4.	Heat Stroke or heat exhaustion?	NO	YES
	5.	Diabetes mellitus (sugar)?	NO	YES
	6.	Hemophilia (bleeding disorder?	NO	YES
	7.	Bone or joint problem?	NO	YES
	8.	Heart Problem?	NO	YES
	9.	Hearing or vision problems?	NO	YES
	10.	Eye glasses, contact lenses?	NO	YES
	II.	Dentures or hearing aid?	NO	YES
	12.	Loses of function of a body part?	NO	YES
	13.	Require a special diet?	NO	YES
	14.	Special psychiatric needs?	NO	YES
	15.	High blood pressure, hypertension9	NO	YES
If the answer to any of the above questions is “yes”, explain fully below. Give details as in whets the event occurred, your child’s current status., and any
special needs that he now has.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medications:		
1.

2.

3.	NAME	EXACT DOSAGE	SPECIFIC TIME GIVEN

		
Allergies. List:

Tetanus Booster. Date;	

PARTICIPATION RELEASE (If applicant is under 21 years old)
I hereby give my permission for (child’s name) __________________________________ to participate in the Omega Psi Phi Fraternity. Inc activities and events. I also grant to the Omega Psi Fraternity, Inc. permission to record my child/ward’s likeness and or voice for use by television, films, radio or printed media to further the aims of the Omega Psi Phi Fraternity, Inc. in related campaigns, magazines articles. booklets, posters, and in other was it sees fit. I hereby release Omega Psi Fraternity, Inc., its insurer, agents, heirs, successors and assigns from any and all liabilities and claims in connections herewith.

CONSENT TO TREAMENT/EVIDENCE OF INSURANCE
In the event that my child should for any reason require any minor or surgical treatment and/or medication during the course of his attendance at or participation in the Omega Psi Phi Fraternity, Inc. activities. I authorize such physician or emergency care staff that Omega Psi Phi Fraternity. Inc. may appoint or designate to carry out the necessary treatment, or to take my child to the emergency room of any hospital, and further authorized the hospital and its medical staff to provide the treatment deemed necessary by them for the well being of my child. It is understood, however, that if hospitalization or treatment of a more serious nature is required I will be contacted, if at all possible, by telephone for permission.

I, the undersigned, am a parent or legal guardian of the above specified child. I have read and fully understand the provisions of the above releases and have explained them to said minor. I further declare that all of the statements that I have made herein, are true to the best of nay knowledge, information and belief. I hereby agree on behalf of myself and my child to hold harmless and release the Omega Psi Phi Fraternity, Inc.. the attending physician(s). hospital, their insurers, agents, heirs, successors and assigns from any and all liabilities and claims arising out of any treatment rendered to my child.

Parent or Legal Guardian Signature  _____________________________________________	DATE:  _______________________________

Ωφελημα Ψυχι Φιλια
Friendship is Essential to the Soul
Page 21 of 23
	FORM 9A
Attachment Ill
Revised 03/06

OMEGA PSI PHI FRATERNITY, INC
RELEASE OF LIABILITY FOR REIMBURSEMENT OF PROCESSING
FEE
BY the Releaser(s)_________________________________________________  referred to as “I”,

TO: The Omega Psi Phi Fraternity, Inc., the___District of the Omega Psi Phi Fraternity, Inc., and_____________Chapter, “an unincorporated association of the Omega Psi Phi Fraternity, Inc.:, their officers, members, agents, employees and/or assigns, referred to as “You”,

If more than one person signs this Release, “I” shall mean each person who signs this Release.

I. Release. I release and give up any and all claims and rights which I may have against you pertaining to my right to recover the portion of sums designated as a “processing fee” which was remitted by me to You. This releases all claims, including those of which I am not aware and those not mentioned in this Release, which pertain to my right to recover said processing fee.

IT IS EXPRESSLY UNDERSTOOD AND AGREED that I have attended an “Information Session”, which I understand to be a segment of the Membership Selection Program of the Omega Psi Phi Fraternity, Inc., sponsored by and through the ______District of the Omega Psi Phi Fraternity, Inc., and that I have remitted the sum of $1,050.00 (G) or $845.00 (UG) as required by my attendance at the Information Session.

IT IS EXPRESSLY UNDERSTOOD AND AGREED that remittance of the aforementioned sum is not a
promise, guarantee, or made in consideration of membership into the Omega Psi Phi Fraternity, Inc., the _____District of the Omega Psi Phi Fraternity, Inc., and br___________________Chapter of the Omega Psi Phi Fraternity, Inc. I fully understand that my admission to membership into the Fraternity shall be governed by the rules promulgated within the Membership Selection Program Handbook.

IT IS EXPRESSLY UNDERSSTOOD AND AGREED that I shall be entitle to a refund of all other sums
remitted by me at the “Information Session” except for the processing fee of $105.00 (G) or $84.50 (UG)

IT IS FURTHER EXPRESSLY UNDERSTOOD AND AGREED that the remittance of $945.00 (G) or
$760.50 (UG), which is the remainder of the monies submitted by me after the deduction of the processing fee, by “You”
is in full accord and satisfaction, and in compromise of all disputed claims and I understand that I ani not entitled to recover any further sums from “You”.

IT IS FURTHER EXPRESSLY UNDERSTOOD AND AGREED that remittance of the sum of $945.00 (G)
or $760.50 (UG), shall be made in accordance with the rules set forth by the Membership Selection Handbook of the Omega Psi Phi Fraternity, Inc. or as designated by the Grand Basileus of the Omega Psi Phi Fraternity, Inc., or his designee.

2.	Who is Bound. I am bound by this Release. Anyone who succeeds to my rights and responsibilities, such as
my heirs or the executor of my estate, is also bound, This Release is made for your benefit and all who succeed to our rights and responsibilities, such as your heirs or the executor of your estate,
3.	Governing Law. This agreement shall be deemed a contract entered into pursuant to the laws of the District
of Columbia and shall in all respects be governed, construed, applied and enforced in accordance with the laws of the District of Columbia.
	4.	Signatures.	I understand and agree to the terms of this Release.

Witnessed or Attested By:

_______________________________		___________________________________
	(Seal)	         	 (Candidate)
FORM 9A
	Attachment IG
	Revised 03/06

OMEGA PSI PHI FRATERNITY, INC
Transcript

Please attach an official copy of transcript.

Ωφελημα Ψυχι Φιλια
Friendship is Essential to the Soul
Page 23 of23