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SUPPORT HIIU’s INITIATIVE

There is strength in numbers. If a critical number of Utah's citizens and corporations join together in a common effort, meaningful healthcare reform can be achieved.

By supporting HIIU's initiative, you are simply adding your name to the list of those who would like to see HIIU's project succeed. There is no other commitment. Your support does not imply any binding or contractual obligation.

Personal and/or Corporate Support. Please check all that apply.	Corporation Self Employed Individual Family

Corporate / Business Name

Contact Person / Title

Number of Employees (including self)

Address

City, State, Zip

Phone

E-mail

Individual or Family Name

Number of Family Members (including self)

address

city,state, zip

Phone

E-mail

Healthcare insurance companies and/or Third Party Administrators that you utilize

For Individuals and Families: Physicians that you visit

Memberships and Affiliations (such as Chamber of Commerce, Vest Pocket, PTA…)

HIIU may use my/our name in its promotional and educational material:	Yes No

I / we may be interested in serving on HIIU’s Advisory Board or one of its committees:	Yes No

I / we would like to receive e-mail updates from HIIU	Yes No


HIIU has applied for 501(c)(3) status. Donations will be accepted

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