Application for Membership
United Restaurants of NY, Inc.®

Please complete the information below. Dues are $85.00 per year. A United Restaurant representative will contact you shortly to arrange for benefits. 

Contact:
Title:
Company:
Address:
City:
State:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KT LA MA MD ME MI MN MO MT NE NC ND NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip:
Phone:	(### - ### - ####)
County:
Date Firm was Formed:
FAX:	(### - ### - ####)
E-mail:
My Company is a:	Corporation Partnership Sole Proprietor Other
Owner/Partners Name(s):
Number of Employees:
Payment Information. Annual Dues=$85.00
Enclosed is my check for:	Check #

Mail your completed form to:

United Restaurants of New York ®
PO Box 769
Armonk, NY 10504