Discount Program Participation Application for Multiple-Location Merchant

* Designates required information
Contact Info
Contact Address
Discount Information

Company Info
Company Address
Location 1
Location 2
Location 3
Location 4

By submitting this application, you indicate that you have read and agree to meet the above criteria and that all information included on your application is correct. Your participation in the program will be subject to ongoing review by Intermountain, and we reserve the right to discontinue your discount if the participation criteria are not met.

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