APPLICATION AND/OR RENEWAL
FOR MEMBERSHIP
THE INDEPENDENT NURSING HOME ASSOCIATION
 

I, HEREBY APPLY, on behalf of the hereinafter named nursing home, for membership in the Independent Nursing Home Association. (The Applicant, if accepted, will conform to the Codes of Ethics, Constitutions and Bylaws of this Association.)

The information supplied hereinafter is accurate to the best of my knowledge and belief. I hereby authorize the Independent Nursing Home Association to make such inquiries as it may desire to verify the qualifications of the nursing home for membership therein.

I HEREBY AGREE TO SUBMIT MY CHECK WITHIN TEN (10) DAYS OF APPLICATION APPROVAL AND MONTHLY THERE AFTER, IN PAYMENT DUES. Annual Dues are calculated at $68.00 per bed for each facility

 


Name: ____________________________________________________________ Title: __________________________ Date: ______________

Name of Nursing Home: ________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________________

Phone: _____________________________________________________ Fax: _____________________________________________________

Mailing Address (if different): ____________________________________________________________________________________________

State Classification Ownership (Proprietary, Church, Non-Profit): ________________________________________________________________

With what other Nursing Homes in the State of MS are you related, either through common ownership, common management, or otherwise?

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Please list the names and mailing address of the principal owners of the nursing home:

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(Do Not Fill In Below This Line)

Recommendations of Membership Committee: Approval ( ) Rejection ( )

If Rejection is marked, state grounds: ______________________________________________________________________________________

Chairperson: ______________________________________________________________________ Date:_______________________________

Action of Board: ___________________________________________________________ By: __________________________ Board President