Utah Tobacco Free Alliance Membership Form
Complete the form below to sign up for our membership service
Name
*
First Name
Last Name
Email
*
example@example.com
Job Title
*
Professional Phone Number
*
Please enter a valid phone number.
Professional Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What company are you associated with?
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UTFA Membership
If you have multiple members with your agency, please have EACH MEMBER fill out this survey.
Are you a first-time member?
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Yes
No, I am renewing my membership
Are you part of an agency or attending as an individual?
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Agency: local & state health departments, non-profits, organizations, representative of agency.
Individual: students, healthcare professionals, community members.
UTFA focuses on three areas of participation. Which work group are you interested in joining?
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Community Advocacy & Education: prevention, cessation, & control policies.
Clinical & Health Systems: connect clinicians, health care systems, & facilitate prevention.
Business: Develops and facilitates comprehensive tobacco-free campuses & cessation.
Non-participating member, updates only.
Please choose your desired membership.
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Individuals Active Member: $50.00 annually (Not representing organization, work group, meetings)
Agency Active Member: $100.00 annually (Representing organization, one fee multiple members, work group, meetings)
Non-Participating member: $0 (emails)
We noticed that you selected Non-participating membership. Please tell us why you chose that option
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Payment Information
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Agency Active Membership
$
100.00
Individual Active Membership
$
50.00
Credit Card
UTFA Interests
Where did you hear about us?
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Networking
Work
Google
News article
Other
Why are you interested in being a member of UTFA? If you are renewing your membership, what would you like to see from UTFA?
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Are you interested in future leadership positions at UTFA?
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Yes
No
Verification
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I certify that I do not work in or have ties to the tobacco industry.
Thank you for submitting your application and payment. Your membership payment helps UTFA efforts in reducing exposure and use of tobacco and nicotine products in Utah. We will contact you shortly to verify your application and share meeting details.
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