Junior Professional Membership Application

Name *

First

Last

Nick Name

Email *

Cell Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

High School *

University *

Major

GPA

Hobbies

Active Organizations

Social Media Profile

Please provide a link to a social media profile – ie. Facebook, LinkedIn, Instagram

Resume

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

Nominee Bacchus Affiliations

Nominator *

First

Last

Nominator Bacchus Affiliation *

Nominator Email *

Nominator Phone *