Site Information: *

A "site" is a physical location of your company. All sites are considered members. Please complete a copy of this side of the application for each site and designate one the Main Site. (Photocopy this page as necessary)

This is the ONLY Site

Multiple Sites (This is the Main Site)

Multiple Sites (This is NOT the Main Site)

Private Duty/Private Pay (Stand Alone): By clicking yes, you are confirming that your Agency does not participate in Medicaid and/or Medicare. *

Yes

No

Company Address: *

This Site

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone: *

Country

(###)

###

####

Fax:

(###)

###

####

Contact Person: *

First Name

Last Name

Operational Structure:

(check all that apply)

Freestanding

Freestanding/Franchise

Government Based

Hospital Based

Nursing Facility

Hospital Affliated

Not-For-Profit

Proprietary

Tax Exempt (Please attach letter of tax exemption)

Ownership Control:

(check one)

Voluntary Non-Profit - Church

Voluntary Non-Profit - Other

Proprietary Sole Proprietor

Proprietary Partnership

Proprietary Corporation

Private, Non-Profit

Governmental, City/County

Other

Affiliations/Accreditations:

(check all that apply)

Accredited Organization

MHPCA Member

National Alliance

HCAOA

MALA

MCHS Member

MoADSA Member

VNAA Member

Leading Age

MHC