Membership Application: Assisted Living Center

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Community Information:
Community Name:*
Administrator:*
Address:*
Street Address Address Line 2 City State ZIP Code
Phone:*
Fax:
Email:*
Website:
State License(s) Supervisory:*
State License(s) Personal:*
State License(s) Directed:*
Annual Membership Dues Rates – 2024
Arizona Health Care Association (AHCA): $13.82 per licensed bed
American Health Care Association (AHCA): $11.03 per licensed bed
Annual Total: $24.85 per licensed bed
Total # of Units:
Total # of Proprietary:
Total # of Non-Proprietary:
Your Name:*
Your Email:*
Main Point of Contact:
Manager/Administrator Name:
Title:
Address:
Street Address Address Line 2 City State ZIP Code
Phone:
Fax:
Email:
Owner Information
Owners Name:
Address:
Street Address Address Line 2 City State ZIP Code
Phone:
Fax:
Email: