Date Name of Facility Telephone Address Information Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Fax Number Facility Website Number of Beds Skilled Beds Intermediate Care Beds Residential Care Beds (Level IV) Total Beds Facility License Number Date Acquired Do you or your organization own any other facilities in Massachusetts? Type of Ownership Proprietary Non-Profit Legal Ownership Proprietorship Partnership Corporation Names of Owner, Partners, Members of Corporation Name of Administrator/Executive Director Administrator Email Names of Person (state position) who will represent the facility in the Association if not Administrator References (minimum of 2) physician, hospital or other nursing home and/or commercial or banking and finance (for organizations, please name individual to contact). Please supply the names and telephone numbers. physician, hospital or other nursing home and/or commercial or banking and finance (for organizations, please name individual to contact). Please supply the names and telephone numbers. physician, hospital or other nursing home and/or commercial or banking and finance (for organizations, please name individual to contact). Please supply the names and telephone numbers. physician, hospital or other nursing home and/or commercial or banking and finance (for organizations, please name individual to contact). Please supply the names and telephone numbers. Add more items more items Agreement If accepted to membership, I pledge, on behalf of the facility, to abide by the laws, bylaws, and professional ethics and standards of the Massachusetts Senior Care Association. In the event of termination of membership, it is hereby agreed that any and all certificates and other indications of membership will be promptly surrendered. I Accept