Membership Application

Complete the form below to submit a new Membership. Once all the required fields have been completed, click the Submit Membership button.

Note: If you need to renew your UMR-ACUHO membership, do NOT fill out this membership application form. Instead, the SHO can log in to the members only area. Once logged in, go to "Manage Institution". This will be a prepopulated form with your school's data. Update any of the data and select renew at the bottom of the page. This will bring you to the payment screens. If you pay via credit card, all online services related to membership will be restore for each of your staff members. If you pay by PO/Check, the services will be restored after payment is received.

Membership Type:
Institutional Individual

Membership Level
Individual: $20
Institute (1-1,000 Fall Occupancy) $55
Institute (1,001-2,000 Fall Occupancy) $110
Institute (2,001-3,000 Fall Occupancy) $165
Institute (3,001+ Fall Occupancy) $220

Organization Information

Organization Name:

Address 1:

Address 2:

City:

State:

Zip:

Type of Institution:
Public Private

Primary Phone:(###-###-####)

Secondary Phone:(###-###-####)

Fax:(###-###-####)

Wesbite URL:(Include http://)

Total Fall Housing (Males):

Total Fall Housing (Females):

Total Occupancy Capacity (Males):

Total Occupancy Capacity (Females):

Member Information

First Name:	Middle Initial:	Last Name:
Title:
Address 1:		Address 2:
City:		State:	Zip:
Work Phone:(###-###-####)		Mobile Phone:(###-###-####)
Fax:(###-###-####)
Email/Username:		Password:

Billing Information

How would you like to pay for your purchase?(please choose one)
Check or Purchase Order Credit Card

Billing address same as above

First Name:

Last Name:

Address:

City:

State:

Zip:

Name as it Appears on Card:

Credit Card Number:

Expiration Date:(MM/YYYY)

Security Code:

Platinum Plus Corporate Sponsors:

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Member's Login

Membership Application

Organization Information

Member Information

Billing Information