Payment for UHCA Individual Membership Application

Annual dues for Associate Individual Membership is $200.00.

I herby make application for Associate Individual 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.

*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 *

Address 2

City *

State *

Zip *

Phone *

Email *

Nature of Business / Interest in the Long-Term Care Profession *

Total Amount

Payment method *

Credit Card
Mail Check / No Payment Due

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*