USHA Membership Application

Name:______________________________________________________
Address:____________________________________________________
City:___________________________State:________Zip:_____________
Birthdate:____________________________________________________
Home Phone:_____________________Work Phone:_________________
Primary Email Address:_________________________________________

Ship To Address (If different from billing address)

Address:_____________________________________________________
City:___________________________State:________Zip:______________

Choose Your Membership
One year - $45
One Year Booster - $85 (includes 1-year membership, booster gift and $25
tax deduction)
Three year - $120 (you save $15)
Three Year Booster - $235 (includes 3-year membership, booster gift and
$100 tax deduction)
Junior (19 & Under) - $15
Full-time student (23 & Under) - $15

Method of Payment
Check is enclosed (pay to the order of: USHA)
Charge my card (MasterCard, Visa, American Express, Discover)
Card #:_______________________________________________________
Expiration Date:________________________________________________

Please send form to:
USHA, 2333 N. Tucson Blvd., Tucson, AZ 85716