Your Name:*

Your Email:*

Licensure Information

# of Licensed Beds:*

Are you Not-For Profit?*

What services does your facility offer?

This information will be published in the directory.

Other Service:*

Facility Information

Facility Name:*

Administrator:*

Address:*

Street Address City State ZIP Code

County:*

Email:*

Phone:*

Fax:

Ownership/Operating Information

Owner/Parent Company:

Address:

Street Address City State ZIP Code

Contact Person:

Phone:

Fax:

Email:

Has the ownership of this facility changed within the last 12 months?*

No
Yes

Date Ownership Changed:*

Name of Previous Owner:*

Management Company Information (If Applicable)

Management Company Name:

Address:

Street Address City State ZIP Code

Contact Person:

Phone:

Fax:

Email:

Has the Management Company of this facility changed within the last 12 months?

No
Yes

Date that the Management Company Changed:

Name of Previous Management Company:

Regional Contact (If Applicable)

Regional Contact Name:

Title:

Address:

Street Address City State ZIP Code

Phone:

Fax:

Email:

Administration Information

Director of Nurses:

DON Email:

Director of Staff Develpoment:

DSD Email:

Director of Admissions:

DOA Email:

Dues/Seminar Invoices

Send CAHCF Dues Invoices to:*

Facility
Owner
Corporate Office

Send Seminar Invoices to:*

Facility
Owner
Corporate Office

Dues Payment Will be Paid:*

Monthly
In Full by February 1, 2015

Invoices to be sent via:

Mail
Email

Contact:

Company Name:

Address:

Street Address City State ZIP Code

Phone:

Fax:

Email:

Facility Membership Application