VHSG Membership Application

For Businesses in Vermont Health Services Group Health Plan with Blue Cross Blue Shield of Vermont

Introductory offer of $120!

Retail Membership - Persons, firms or corporations with established places of business, engaged in the retail selling of foods and such other commodities as are usually sold in retail food stores.

Associate Membership - Open to businesses that supply products or services to food stores.

Associate Program Membership - Open to all businesses that are not food stores, but wish to participate in association programs, such as the VHSG health insurance.

Upon submission, VGA will invoice you for the membership dues as indicated below or you may pay online using the convenient PayPal option.

*Store Name:
*Owner(s) or Contact:

Store Location:

*Street:
*City:		*State:		*Zip:

Mailing Address (*If different from above):

Address:
City:	State:	Zip:

*Bus. Phone:		Home Phone:
Fax:		Email:

Previous Owners:

*Membership Dues

$120.00 (Retail)

$120.00 (Associate)

$120.00 (Program Membership)

* Required Fields

Membership Runs Through the end of December 2010
Your payment carries you from date of joining to through the end of December 2010.

Membership dues to the Vermont Grocers' Association are not deductible under IRS regulations as a charitable donation, however they are generally allowed as ordinary and necessary business expenses subject to the restrictions imposed in the Omnibus Budget Reconciliation Act of 1993 related to lobbying activity. VGA estimates that the portion of your dues allocable to lobbying (and therefore non-deductible) is 40%.