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Registration/payment for Associate Business Membership

I herby make application for Associate Business Membership to the Utah Health Care Association (UHCA). I agree to abide by the rules, bylaws and standards established by and for the members of UHCA.

Choose your membership level below.

*Dues payments may be deducted as an “ordinary and necessary” business expense.
*Contributions or gifts to UHCA may not be deducted as charitable contributions.

First Name *

Last Name *

Business *

Address *

Address2

City *

State *

Zip *

Company Website

Phone *

Email *

Representative contact name, if different from above:

Representative contact email:

Representative contact phone:

I am joining at the:

Platinum Level ($4,500 annually)

Gold Level ($3,400 annually)

Silver Level ($2,300 annually)

Bronze Level ($1,200 annually)

I am a current 2021 Associate Business Member renewing for 2022 at the:

Platinum Level Renewal ($4,000 annually)

Gold Level Renewal ($3,000 annually)

Silver Level Renewal ($2000 annually)

Bronze Level Renewal ($1,000 annually)

If you checked 'other,' please enter amount (no dollar sign or punctuation).

In addition, we would also like to be a sponsor of:

1-Day Workshop/Seminar Sponsor for 1 Upcoming Event $2000

Logo/Link on UHCA Homepage Website for 12 Months $1500

Banner Advertisement on the Homepage of UHCA’s Website-6 months $750

Digital Advertising Package $2000

Social Media Post $100

2 Email Advertisements to Members $500

Other amount (please specify below)

Total Amount

Payment method *

Credit Card via Authorize.net
Mail Check / No Payment Due

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*

Verification code*

4970 South 900 East, Suite C, Salt Lake City, Utah 84117

Phone: 801-486-6100

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