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Nursing Homes Membership Application

Required Information is marked by an asterisk (*)

Facility: *
Contact Person: *
Licensed Beds Capacity:
Address: *
City, State Zip: *
Phone: *
Fax:
E-mail: *
Website:
Licensure Level:

Ownership:

Non-Profit:
Proprietary:
Government:

Certification:


If chain-owned, name of chain:

Name of Administrator: *
Name of Director of Nursing: *
Authorized Voting Representative (if other than administrator): *
Comments or Questions: