PUBLIC SERVICE ACTIVITY VERIFICATION FORM

Date:

Location:

Contact Information:
Name of organization:
Address:
City, State Zip code
Phone number:
Email:

Contact Person(s): Name of contact person at the agency or university official that can verify the chapter participated in the public service activity. 
 

Participant(s): Names of member(s) who participated in the public service activity.

Signature of Contact Person(s)