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:
   
  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:
* Card Number:
* CVV Number:
* Expiration: (MM/YY)
* Name of Cardholder:
* Cardholder Address:
* Cardholder City:
* Cardholder State:
* Cardholder Zip Code: