This form is for New Membership Applications/Renewals/Requesting Invoices

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

** This form can be used to request an invoice, complete all information except the payment information. Leaving the payment information blank will prompt our office to send an invoice to the email provided. **

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

As of Jan 1, 2022 the Institutional Membership base rate increased by $175.

Number of TRIO Programs

How many TRIO Programs are at your Institution? *

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: (leave blank if requesting invoice)

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: (leave blank if requesting invoice)

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