ASUA Membership Types

Arizona Small Utilities Association Membership Application

Please fill out the information below. Required Fields are marked with an asterisk (*).

MEMBER INFORMATION

* Name of Member:

* Mailing Address:

* City:

* State:

* County:

* Zip Code:

* Phone:

Fax:

* Contact Name:

* Email Address:

Web Site URL:

Area Population:

Service Connections:

* Type of Utility:

Federal	Tribal	State
Municipal	Water District	Sanitary District
Improvement District	Association/Co-op	Non-Profit Corp
For Profit Corp	Private Owner	Other

LEGISLATIVE INFORMATION

Congressional District:

Legislative District:

Congressman:

State Senator:

State Representative 1:

State Representative 2:

PAYMENT INFORMATION

Membership Type:
(See all membership types)

Check all That Apply - (See all membership types)
Utility ($75 + $0.55 per connection to a Maximum of $750)
Utility/Operator (Utility membership + $40)
Individual ($75)
Non-Voting Professional ($125)
Industry ($400)

* Total Payment Amount:

Payment Type:

Visa

Mastercard

Amex

Discover

* Card Number:

* CVV Number:

* Expiration:

(MM/YY)

* Name of Cardholder:

* Cardholder Address:

* Cardholder City:

* Cardholder State:

* Cardholder Zip Code: