Boulder Interdisciplinary Committee

BOULDER INTERDISCIPLINARY COMMITTEE

P.O. Box 270435, Louisville, Colorado 80027

Phone: 720-232-4573 www.boulderidc.org

2015-2016 RENEWAL, NEW MEMBER APPLICATION & DIRECTORY INFORMATION

Completed applications must be received by November 1, 2015

*All applications received after the due date will be added to the online directory only, and will not be in the paper directory.

Check her if all info is the same: _____

Please update all information that has changed!

NAME & TITLE: ______

Business/Organization Name: ______

MAILING ADDRESS: ______

CITY: ______ZIP CODE: ______

BUS. PHONE: (_____) ______FAX NUMBER: (____) ______

EMAIL ADDRESS: ______

(Important for meeting reminders, updates, IDC news, etc.)

WEBSITE ADDRESS: ______

Please check all that apply:

Attorney _____ Mediator ______Mental Health Professional ______Community Service Organization ______

ADR ______CFI ______PC ______DM ______

GAL ______PRE ______

SPT ______TSPT ______

Voting member?______

Please provide the following information: If this is a renewal and all of the information remains the same, make that notation on this form.

PRACTICE/SERVICE PROVIDED: ______

______

______

______

EDUCATION/ CERTIFICATION: ______

______

______

EXPERIENCE: ______

______

______

______

PROFESSIONAL MEMBERSHIPS: ______

______

______

Note: Please note that the completion and return of this application constitutes an

affirmative statement that all professional licenses or certifications listed

herein are in effect, and there is no current barrier to the applicant practicing

in any capacity or professional area listed in the application.

FEES: ______

DO YOU HAVE REDUCED FEES OR DO PRO-BONO WORK? yes no

CAN WE PUBLISH REDUCED FEES OR PRO-BONO IN THE DIRECTORY? yes no

Please note: BIDC Policy is that no announcements for professional services, workshops, office rentals, classes, etc. shall announced at luncheons. Any announcements such as these may be printed and displayed on the marketing table near the check in area at each monthly meeting. You may also utilize the BIDC Membership Directory to communicate with BIDC Members.

Lunch Costs: Member=$25 each month, Non-member=$30 each month

PLEASE CHECK ONE:

_____ $140=ONE YEAR MEMBERSHIP RENEWAL (current member) or

_____ $120=First time, never been a member MEMBERSHIP

_____ $70=- Non Profit Organization (Please show verification)

______ADD (optional) $200= LUNCH PAYMENT FOR FULL PROGRAM YEAR

(Please note, we have 9 lunches instead of 8 this year. Paying ahead for the year

includes one free lunch: 8 lunches @ $25 = $200 + membership fee above)

______ADD (optional)=$5 each ~~I would like my directory sent via US Mail.

______ADD (optional)=$5 each ~~I would like an additional directory.

Note: all members receive one complimentary directory

TOTAL INCLUDED $______

COMPLETED APPLICATIONS MUST BE RECEIVED BY November 1, 2015 TO BE INCLUDED IN THE MEMBERSHIP DIRECTORY! No exceptions!

Applications are only accepted electronically this year.

BIDC meetings will be held at the Millennium Harvest House,

1345 28th Street, Boulder, CO 80302

www.millenniumhotels.com/Boulder

2 WAYS TO COMPLETE YOUR MEMBERSHIP APPLICATION!

Go to boulderidc.org, fill out your membership form and pay by SQUARE!

or make your check payable to Boulder IDC and mail to:

Boulder IDC

P.O. Box 270435

Louisville, CO 80027

*Note: New address!*

Questions? Call cindy at 720-232-4573