I, HEREBY APPLY, on behalf of the hereinafter named business, for Associate Business membership in the Independent Nursing Home Association. I understand that as an Associate member of the Independent Nursing Home Association, I am entitled to all the privilege (with the exception of voting) of the Association.
The following information being supplied to you is accurate to the best of my knowledge and belief.
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Name of Business: ____________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________
Phone: _____________________________________________________ Fax: ____________________________________________________
Type of Business: _____________________________________________________________________________________________________
Contact Person: _______________________________________________________________________________________________________
With what other business in the State of MS are you involved, either through common ownership, common management, or otherwise?
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