This form is for New Membership Applications and Renewals

*If using a card as payment, please confirm the limit will cover the amout due prior to submitting this form.

Questions? Contact Vanessa Ramirez at vanessa.ramirez@coenet.org

Product Selection:

Please Choose an Institutional Membership level in accordance with the number of TRIO Programs your institution hosts:
* 🛈

Bill To Address:

First Name *

Last Name *

Title: * 🛈

Institution/Agency: * 🛈

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).

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

Credit 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 Paying with A Check:

Complete this form, print and mail it along with your check payment to:

Council for Opportunity in Education
P.O. Box 742282
Atlanta, GA 30374