Transcript
APPLICATION FOR MEMBERSHIP
Business Partner (private, for-profit companies or organizations) 2016–2017
Use this application to begin a new or to reinstate a lapsed membership. *information required
Company Information Company Name* Street Mailing Address* City, State and Zip* Company URL/Web Site*
Main Phone Number
Primary Contact—(decision-maker responsible for maintaining the organizational membership) Name/Primary Contact*
Title*
E-mail Address*
Fax
Telephone*
Member Dues (Membership Year June 1, 2016–May 31, 2017) o Large Business Partner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Amount Due: $1,793
o Small Business Partner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Amount Due:
$732
Revenue < $250,000 and less than 2 staff
o EACUBO ($500)
o SACUBO ($500)
0.00
+ Regional Dues: $
0.00
= TOTAL DUES:* $
0.00
* Please submit membership dues payment with application
You may also apply for regional membership. Check any that apply: o CACUBO ($500)
$
NACUBO Dues:
Revenue >= $250,000 and 2 or more staff
o WACUBO ($500)
Regional membership is optional to join NACUBO. Organizations may list two staff per region.
Payment Please make check payable to NACUBO and mail payment with this application to: NACUBO Member Services, 1110 Vermont Ave., NW, Suite 800, Washington, DC 20005, or complete the information below to pay your total dues by credit card and fax to 202.861.2583. o American Express
o Diners Club
o MasterCard
o Visa
Card Number: Expiration Date:
Security Code*:
Signature Date Print Name Title * Where do I find this Security Code? Visa and MasterCard Users: Look at the signature box on the back of your card. You should see either the 16-digit credit card number or just the last 4 digits followed by a 3-digit code. This 3-digit code is your Security Code. American Express Users: Look for the 4-digit code printed on the front of your card just above and to the right of your credit card number. This 4-digit code is your Security Code.
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Individuals Receiving Member Benefits Depending on which business partner membership is purchased, you will be entitled to either 2 or 5 staff receiving member benefits. Additional staff above the limit will be $300 per person. Please list those individuals below (Large Business Partner = 5, Small = 2, For-profit Higher Education = 5): 2. Name Title E-mail Address Telephone
Fax
Address (if different from company address)
3. Name Title E-mail Address Telephone
Fax
Address (if different from company address)
4. Name Title E-mail Address Telephone
Fax
Address (if different from company address)
5. Name Title E-mail Address Telephone
Fax
Address (if different from company address)
WASHINGTON
MONTANA
MAINE
NORTH DAKOTA MICHIGAN
OREGON
VT
MINNESOTA IDAHO
SOUTH DAKOTA
WISCONSIN
NEW YORK
CONN
MICHIGAN
WYOMING
PENNSYLVANIA
IOWA
NEVADA
NEBRASKA
OHIO
UTAH
ILLINOIS
CALIFORNIA
DC
INDIANA
COLORADO
WESTVIRGINIA KANSAS
VIRGINIA
MISSOURI KENTUCKY
NORTH CAROLINA TENNESSEE OKLAHOMA
ARIZONA
SOUTHCAROLINA
ARKANSAS
NEW MEXICO
ALABAMA LOUISIANA TEXAS
NH MASS RI
NEWJERSEY DELAWARE MARYLAND
Color Key: CACUBO EACUBO SACUBO WACUBO
EACUBO/SACUBO SACUBO/CACUBO EACUBO/CACUBO SACUBO/WACUBO
GEORGIA
MISSISSIPPI
ALASKA
FLORIDA
HAWAII
Business Partners are allowed to join as many regions as they would like. Regions are primarily divided geographically. Please make your selection below and add to NACUBO dues balance (page 1). Central Association of College and University Business Officers (CACUBO) . . . . . . . . . . . . . . . . $500 Eastern Association of College and University Business Officers (EACUBO) . . . . . . . . . . . . . . . . $500 Southern Association of College and University Business Officers (SACUBO) . . . . . . . . . . . . . . . $500 Western Association of College and University Business Officers (WACUBO) . . . . . . . . . . . . . . . $500 Please Note: Business Partners may neither hold office nor be eligible to vote. 2
