Please mail the original of this form, together with your Fraternity’s Fair Share Contribution (in whole or in part) and the Treasurer’s Annual Report Form to the REGIONAL TREASURER (see Regional Directory for name and address).  A copy of these forms is to be included with your Annual Report and e-mailed to the Regional Minister (see Directory for name and e-mail address).  Please make your check payable to:  ST. KATHARINE DREXEL REGION.  Thank you.

AMOUNT DUE PER ACTIVE PROFESSED MEMBER AND CANDIDATE $30

FRATERNITY NAME:                                                                                                                                                
Minister:                                                                                                                                               
Street Address:	                                                                                                                                               
City, State and Zip Code:
Phone Number:					Cell Phone:
E-MAIL:

Treasurer:                                                                                                                                               
Street Address:                                                                                                                                               
City, State and Zip Code:
Phone Number:						Cell Phone:		
E-MAIL:
 
TOTAL NUMBER OF
	ACTIVE PROFESSED: 				CANDIDATES:
(These numbers should coincide with the number reported on the Annual Report.)

AMOUNT ENCLOSED:		$			Full Payment  [   ]	Partial Payment   [   ]