Facility Membership Application Your Name: * Required First Last Your Email: * Required Facility Type: * Required Nursing Home Assisted Living # Nursing Home Beds * Required# Assisted Living Beds * RequiredOptions: Licensed Units For Profit Multifacility Medicare/Medicaid Certified Not For Profit Independent Distribution of Beds# Medicare Beds:# Non-Medicare Beds:# Alzheimer's Beds:# Other beds:Facility InformationFacility/Community Name: * RequiredAddress: * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone: * RequiredFax:Email: * Required Website: - enter a valid website URL for example http://www.google.com Contact Name (Administrator, Executive Director): * Required First Last Operating/Management Company Name:Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Fax:Email: Ownership:Dues Structure Licensed NCF Beds All Beds: $68.55 per bed Assisted Living Residences All Beds: $31.65 per bedPayment Options: * RequiredI will pay my Facility dues in nine (9) monthly installments due the first day of each month, beginning January 1st.I will pay my Facility dues in FULL prior to December 31st. I will receive a 3% discount off my total dues.I will pay my Facility dues in four (4) quarterly installments due the first day of January, April, July and SeptemberWe will contact you for your payment. Please mail application with check attached to: Colorado Health Care Association, 225 E. 16th Avenue, Ste. 1100 Denver, CO 80203 to the attention of Director of Finance.CommentsThis field is for validation purposes and should be left unchanged.
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