Alpha Kappa Alpha, Inc.

SER Office South Eastern Regional Staff South Eastern Regional Committee Chairmen SER Conference Chairmen SER Cluster Coordinators Regional Director Request Form Ivy Beyond the Wall Request South Eastern Swag Shop Ask SER!

Ivy Beyond the Wall Request

Name of IBTW *

Date of Birth *

City of Birth *

State of Birth *

Year of Initiation *

Chapter Initiated *

Last Active Chapter *

Date Became IBTW *

IBTW Ceremony Date *

Location of Ceremony *

Alpha Kappa Alpha Offices Held

Alpha Kappa Alpha Committees Chaired

Other Accomplishments

Professional Background & Accomplishments

Family Background (please ensure correct spellings)

Name of Person Completing Form *

Email of Person Completing Form *

Phone of Person Completing Form *

Name of Family Contact *

Phone of Family Contact *

Cluster to Receive Notification *

* denotes required field