Membership Form – The Idaho Oral Health Alliance

The IOHA membership year is January 1 through December 31. To be eligible to vote in annual elections, you, or your organization must be a paid member by October 31 of the current year. The IOHA is a recognized 501 c 3 charitable organization, so check with your tax advisor on appropriate deductions. Thanks for paying your annual individual OR business membership. Additional donations are always welcome. Your contact information is used solely by IOHA for internal purposes. For more information, email info@idahooralhealth.org

Name*
First Last
Title
Email**
Phone*
Business/Company
Main Contact (if different than above)
Main Contact Email (if different than above)*
License Number (If Applicable)
We recognize that all our members are oral health champions but that some can provide support at a higher dollar amount than others. Please select the level that best meets your capacity. Member benefits remain the same for all levels.
Your Annual Contribution*
- $100 – Individual Champion
- $60 – Individual Promoter
- $40 – Individual Partner
- $500 – Business
- $250 – Nonprofits/Educational Institutions
We deeply appreciate your support.
Other (Additional tax deductible amount)
Total
$0.00
Address*
Street Address Address Line 2 City State ZIP Code
Credit Card
Card Details
Cardholder Name
*Our primary method of contact and information dissemination is by email. Your contact information is solely used by IOHA for internal purposes. When business meetings/conferences are held, all members will be notified via email regarding the date and time. Your support, ideas, and participation are welcome!