Membership Application

Name:
Title:
Organization:
Address:
City:
State:
Zip:
Phone:
Email:
	Individual: $15/Year
	Individual: $70/5 Years
	Organization Partners: $40/Year
	Organization Partners: $170/5 Years
	Corporate Partners: $100 min/Year
	Corporate Partners: $450 min/5 Years
	Student: $5/Year
Payment Options
	Credit card/PayPal
	Make check payable & mail to: Utah Breastfeeding Coalition P.O. Box 16599 Salt Lake City, Utah 84116-0599