Business Membership Form

Please complete and mail or fax to:

VCUAA

Business Membership

P.O. Box 843044

Richmond, VA 23284

fax 804-828-8197

Or call 804-828-2586 to complete your Business Membership by phone.

(Please print clearly)

Business Name ________________________________________________________

Primary Contact _______________________________________________________

Business Address ______________________________________________________

City _____________________________________  State ____   Zip _____________

Phone _______________________________________________________________

Fax _________________________________________________________________

E-mail _______________________________________________________________

Web site _____________________________________________________________

Business Membership Type

___ $1,000   Gold annual

___ $   500   Standard annual

___ $   250   Not-for-profit annual

Select type of payment:

___ Check enclosed (payable to VCUAA)

Charge to:  __ AmEx     __  Discover     __ Mastercard     __  Visa

Credit Card # __________________________________________________________

Expiration date __________________________    Amount $____________________

Name as it appears on the card ___________________________________________

We will contact you to request information for the Business Member page. 

Thank you!