AZ Allies in Medicine Agreement

AZ Allies in Medicine Agreement
Date*

MonthDayYear
Date
Please select Term of Agreement (minimum is one year)*

One year (12 months)Two years (24 months)Three years (36 months)
Company Name*
Name of Contact Person*
Title*
Business Mailing Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
E-mail*
Contact Phone Number*

Area CodePhone Number
Website URL *
Will be used for promotional purposes
Please select annual Partnership Level (See benefits in full agreement attached below):*

$50,000 - 1892 (Exclusive) Level$25,000 - Platinum Level$15,000 - Gold Level$10,000 - Silver Level$5,000 - Bronze Level$2,500 - Supporter Level
Short description of company that can be used for promotional purposes (i.e. mission statement and (or) information and benefits membership should know)*

0/500
Upload company logo.*

Browse Files
JPEG preferred Cancelof
I have read and understand this agreement with the Arizona Medical Association (ArMA) and agree to the terms and conditions set forth.*

I agree
Signature*

Clear
This agreement shall be governed by the laws of the State of Arizona without regard to conflicts of law rules. This agreement represents the entire agreement between the parties in relation to the subject matter of this agreement and supersedes any previous agreement, whether written or oral, between the parties in relation to that subject matter. Any modifications to this agreement must be made in writing and signed by both parties.
Together, we are empowering physicians. Moving medicine. Shaping care.
Thank you for becoming one of ArMA's invaluble partners and believing in our mission. You will now be directed to ArMA's secure website for payment immediately following submission. For questions, please contact Libby McDannell at lmcdannell@AZmed.org or call (602) 347-6920.
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Together, we are empowering physicians. Moving medicine. Shaping care.