PTNSH

For Quick Registration, complete the application below.

You will be registered immediately. You will be registered as a Student Guest until you sign-in and enter your community service.

Once your community service has been entered, your member level will be modified to reflect the appropriate membership level based on hours entered.

It is very important that you only click the 'SUBMIT' button once; multiple clicks will create an error in your registration.

* Required Fields

Personal Information	* First Name	Middle Initial	* Last Name

	* Birth Date (mm/dd/yyyy)	* Sex
		Male Female
Permanent Mailing Address	* Street Address 1	Street Address 2

	* City	* State	* Zip Code

	* Phone (aaa)xxx-nnnn	* E-Mail

School	* School Name	* Graduating Year (yyyy)

	* City	* State	* Zip Code

Service Org 1	Organization Name	Program Name	Verifier's Name
(If needed)
	Street Address 1	Street Address 2

	City	State	Zip Code

	Phone (aaa)xxx-nnnn	E-Mail

	Start Date (mm/dd/yyyy)	End Date (mm/dd/yyyy)	Number of hours

Service Org 2	Organization Name	Program Name	Verifier's Name
(If needed)
	Street Address 1	Street Address 2

	City	State	Zip Code

	Phone (aaa)xxx-nnnn	E-Mail

	Start Date (mm/dd/yyyy)	End Date (mm/dd/yyyy)	Number of hours

Service Org 3	Organization Name	Program Name	Verifier's Name
(If needed)
	Street Address 1	Street Address 2

	City	State	Zip Code

	Phone (aaa)xxx-nnnn	E-Mail

	Start Date (mm/dd/yyyy)	End Date (mm/dd/yyyy)	Number of hours

The most important thing I learned from community service is ...

I certify that to the best of my knowledge I have answered the application truthfully.
I understand that if I have misrepresented any information in the application the
Platinum Torch National Service Honorary may consider me ineligible for membership.

* Required Fields

In order to provide members with the list of benefits described, there is a lifetime membership fee of $25.