Name of Fraternity/Sorority:
Name of Person Submitting Form:
Name of Service Project:
Number of Members Participating in Project:
Total Number of Hours Completed:
Description of community service project:
Verification Statement- I certify that my organization completed the service project identified on this form and that all information provided is accurate.
Please provide the below information if you worked with an agency for this community service project. This will assist us to verify the hours if necessary.
Did you work with an Agency Organization for this community service project?
Name of Agency Organization (if you did not work with an agency, type N/A):
Name of Agency Contact Person: