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. U
*Contributions or gifts to UHCA may not be deducted as charitable contributions.

First Name*

Last Name*

Business*

Address*

Address2

City*

State*

Zip*

Phone*

Fax

Email*

Company Website

Other Comments

I am joining at the:

Platinum Level ($4,000 annually)

Gold Level ($3,000 annually)

Silver Level ($2,000 annually)

Bronze Level ($1,000 annually)

Nature of Business*

Booth Selection*

Please choose your top 3 booth choices.

What companies would you prefer not to exhibit next to?

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*