URA Member Application (with Heartland) - Copy 1 Company InformationCompany Name*Contact Name*Email Address* Phone*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Restaurant DetailsChef's NameChef's Email Food & Beverage DirectorFood & Beverage Director's Email Type of RestaurantPrimary CuisineAmenities Banquet Room Liquor License Membership DuesGross Annual Income*$1 to $100,000$100,001 to $250,000$250,001 to $500,000$500,001 to $750,000$750,001 to $1,000,000$1,000,001 to $2,000,000$2,000,001 to $3,000,000$3,000,001 to $4,000,000 Renewal Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name