BACCHUS

Join as a BACCHUS Network Associate Member

Membership

The BACCHUS Network™ is pleased to welcome you as an ASSOCIATE MEMBER, an INDIVIDUAL PROFESSIONAL from a college campus, educational institution, health promotion agency or organization. Your Associate Member affiliation provides discounts to conferences and materials purchases and login access to our health promotion tool kits.

Effective November 5, 2011 by vote of the student delegates, there is a $300 annual fee associated with membership.  This fee is due by March 30, 2012. Each Associate Member must renew annually and pay the $300 membership fee to remain active in The BACCHUS Network.

Note: Please save a copy of this information for your records. Notify us any time your contact information changes.

Once we receive payment, you will receive an email on how to log in to the bacchusnetwork.org website to access information, tool kits, campaigns, and other resources. Please save a copy of this information for your records. There are no refunds granted for membership fees. Fees will be assessed each year in December in advance of the membership year.

Submit for Associate Membership today.

If you have questions, email admin@bacchusnetwork.org or call us at (303) 871-0901.

Once we process your membership, you will receive an email on how to login to our website to access campaigns and other resources.

You will be assigned an access code when you submit this form. Once your membership is fully paid, this access code will allow you access to the resources on our site.

1. Database Maintenance/Correspondence:You are responsible for notifying the national office immediately at any time this information changes.

Date Joining: (date of filing this form - MM/DD/YYYY)

College/University/Agency Name:

First and Last Name:

Office/Department

Professional Title:

Professional E-mail Address:

Mailing Address:

City:

State:

Country:

Zip:

Office Phone:


Method of Payment:

Credit card payments receive a receipt. If you are paying by credit card, you will receive a receipt via email once the card has been successfully processed.

First Name on Card:

Last Name on Card:

Company Name on Card:

Card Billing Address:

City, State and Zip:

Credit Card Type:

Credit Card Number:

Expiration Month and Year:

Please include the invoice that you will receive via email with payment and send to:
The BACCHUS Network
PO Box 100430
Denver, CO 80250-0430

Please include the invoice that you will receive via email with payment and send to:
The BACCHUS Network
PO Box 100430
Denver, CO 80250-0430

Purchase Order Number: