School Membership

School Name: _________________________________
School Advisor: _________________________________
School Address: _________________________________
City: _________________________________
State: _____________________    Zip: ______________
Phone: _____________________  Fax: ______________
 Email: _________________________________
Student Activities Board Members  Position
____________________________________ __________________________
____________________________________ __________________________
____________________________________ __________________________
____________________________________ __________________________
____________________________________ __________________________
% of Budget spent on: Comedy: ____% Lectures: ____% Movies: ____%
  Music: ____% Novelties: ____% Other: ____%
Student Population Demographics
   __ BELOW 3,000 Public:__  Private:__ 
   __ 3,000 – 5000 Commuter: __
   __ 5,000 - 10,000 4-year: __ 2-year: __
   __ 10,000 -15,000 Tech/Trade: __
   __ 15,000 - UP Activities Budget: $ __________
Calculate Totals: TOTALS Below
Institutional Membership Fees to be Charged ($299 per campus): $_________
TOTAL FEES TO BE CHARGED: $__________
Credit Card Information:
__Visa   ___MasterCard  __AmExpress
Card Number: ____________________________
Expiration Date: ______ / _________ Example:(12/2014)
Name on Card: _______________________________
CVV2 Number: _________ (3 digit # on back of card)
Billing Address: ________________________________________
City, State Zip: ____________, ____________ _____________
   
Signature: __________________________________ Date:___/___/___

Signature of Advisor: _________________________ Date:___/___/___
Please Print Advisor´s Name Here: ________________________________
Conference Cooperative Buyer (please print): ______________________________
I have read and agree to abide by the APCA membership policies as outlined on this web site.

FTE Card Applicants:
   NOTE: FTE discounts are only applicable to onsite purchases made at conference.
   # of Full Time Enrolled students: ____________
     Applicable discount:  3%__    5% __   7% __

Faculty confirming full time enrollment of school: ______________________________
Phone number of school registrar's office: ______________________________

Mail this form with You may fax this form with Credit Card information to 865-908-7104 or mail check payable to APCA to:

APCA, P.O. Box 4340, Sevierville, TN 37862
(800) 681-5031