Standard Membership

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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

Contact Person*
First Last
Name of Nursing Home*
Type of Business*
Email*
Phone*
Fax*
Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address (if different)
Street Address Address Line 2 City State ZIP Code
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?*
Please list the names and mailing address of the principal owners of the nursing home:*
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If you have questions, please call our office at 601-325-3298 or e-mail your questions to ashley.inha@gmail.com

Standard Membership

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