Professional Membership Application

Name *

First

Last

Nick Name

Email

Cell Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Occupation

Employer

High School *

University *

Major

Degree(s) Received

How many years has nominee lived in Baton Rouge?

Current/ Past Organizations

Resume

Must be in PDF format to complete upload - Maximum Size 20MB

Prospective Member Bacchus Affiliations *

Nominator *

First

Last

Nominator Status *

Nominator Email Address *

Nominator Phone *

Other Bacchus Members Endorsing Nominee