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Assisted Living/Personal Care Membership


Application and/or Renewal for Assisted Living/Personal Care Membership


(Please complete this entire form)

I HEREBY APPLY, on behalf of the hereinafter named nursing facility, residential care facility, personal care home, assisted living facility, or sub-acute facility, for membership in the Mississippi Health Care Association and the American Health Care Association. I understand that as an applicant, if my membership application is accepted, that my facility will conform to the Codes of Ethics of both Associations, and their respective Constitutions and Bylaws. The information supplied hereinafter is accurate to the best of my knowledge and belief. I hereby authorize the Mississippi Health Care Association to make such inquiries, as it may deem appropriate and desirable, to verify the qualifications of the applicant facility for membership therein.

Name of Facility:
Applicant Name:
Title:
Mailing Address:
City, State, Zip:
Physical Address:
City, State, Zip:
Phone:
Fax:
E-mail:
Website:
Date Licensed by State:
Date of Application:
State Classification:
# of Beds:
Ownership:
(Proprietary, Church
Non-profit)

With what other nursing facility(ies), residential care facility(ies), personal care home(s), assisted living facility(ies), or sub-acute facility(ies) in Mississippi are you related, either through common ownership, common management, or otherwise?
Please list the names and addresses of the principal owners of the nursing facility, residential care facility, personal care home, assisted living facility, or sub-acute facility which is making application herein to the Mississippi Health Care Association.

If you have questions, please call Becky Martin at (601) 956-3472
or e-mail your questions to becky@mshca.com.

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