ASSOCIATE MEMBERSHIP APPLICATION
THE INDEPENDENT NURSING HOME ASSOCIATION
 

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.

 


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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Signature: _________________________________________________________________________ Date:______________________________