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Name (please print) __________________________________________________________________________

Address _____________________________________________________________________________________

City ___________________________________________  State __________  Zip ___________________

Email __________________________________________________________________________________

Presently (check one)

     _______ Teaching

     _______ Not teaching since the date _________________________

     _______ Retired since the date ______________________________

Present or most recent school __________________________________________________________________

Other positions held ___________________________________________________________________________

________________________________________________________________________________________________

Please return form to any Kappa member or mail or fax to:

Kappa Kappa Iota National Headquarters
1875 East 15th Stree
Tulsa, OK  74104-4610
FAX 1-800-678-0389

Or call Kappa Kappa Iota National Headquarters at:                       Find a group near you (click here).
918-744-0389
1-800-678-0389