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COE Institutional Membership
Form for Applications and Renewals
Product Selection:
Please Choose an Institutional Membership level in accordance with the number of TRIO Program your institution hosts:
*
0 - 1 TRIO Programs for $3,250
2 TRIO Programs for $3,650
3 TRIO Programs for $4,050
4 TRIO Programs for $4,250
5 TRIO Programs for $4,850
6 TRIO Programs for $5,250
7 TRIO Programs for $5,650
8 TRIO Programs for $6,050
9 TRIO Programs for $6,450
10 TRIO Programs for $6,850
11 TRIO Programs for $7,250
12 TRIO Programs for $7,650
13 TRIO Programs for $8,050
14 TRIO Programs for $8,450
Bill To Address:
First Name
*
Last Name
*
Title:
*
Institution/Company/Organization:
*
Select Program: (Please only select the program(s) you CURRENTLY have funded on your campus. Leave blank if you do not have any TRIO Programs currently on your campus).
Educational Opportunity Centers
McNair Post-baccalaureate Achievement Program
Student Support Services
Talent Search
Upward Bound
Upward Bound Math/Science
Veterans Upward Bound
Other:
Other:
Address Line 1
*
Address Line 2
Address Line 3
City
*
State
*
Zip
*
Phone
Fax:
Email Address
*
$$ Amount on Credit Card or Purchase Order:
If Paying by Credit Card
Name of person on the credit card (if not the same name above).
Credit Card
Discover
Visa
American Express
Master Card
Card Number
Expiration
Verification Number
If you need a receipt, add the name and address of the person who should receive in the mail
If Paying by Purchase Order
Contact person (person's name and email to send Invoice)
Title and Department
Purchase Order Number:
Purchase Order Date:
Purchase Order Amount:
If You are Paying with A Check
Please complete this form, print the form and mail it along with your check payment to:
Council for Opportunity in Education
P.O. Box 742282
Atlanta, GA 30374