Payment for Corporate Sponsor Application

Please complete the information below to support UHA by committing to the Corporate Sponsor Program.

Sponsorship Level *

Gold member at $5,000

Silver member at $2,500

Bronze member at $1,000

First Name *

Last Name *

Company Name *

Address *

Address2

City *

State *

Zip *

Phone *

Fax *

Email *

Other comments

Total Amount

Payment method *

Credit Card via Authorize.net
Mail Check

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*