Membership Application: Assisted Living Center

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"*" indicates required fields

Community Information:

Community Name:*

Administrator:*

Address:*

Street Address Address Line 2 City State ZIP Code

Phone:*

Fax:

Email:*

Website:

State License(s) - Supervisory BEDS:*

State License(s) - Personal BEDS:*

State License(s) - Directed BEDS:*

Annual Membership Dues Rates – 2025
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: