"To be eligible for ASSOCIATE MEMBERSHIP in the Massachusetts Senior Care Association, an organization must not qualify for facility membership." Company Name Telephone Mailing 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 Website Type of Business? Please give a brief description of your company and how it relates to senior care. Please List Other Professional Associations with Which You Are Affiliated Business Contacts Who is the best contact for each area? Please list their name, title and email address: Primary Contact Name (to be listed on our website) Title Email Billing/Dues Name Title Email Marketing and Advertising Name Title Email Trade Shows Name Title Email Other Contacts Who else in your company should receive Mass Senior Care member news and updates? Name Title Email References References (minimum of two) - One of your references must be a Mass Senior Care facility member or AHCA affiliate organization. Full name Title Organization or facility name Email address Telephone number Operations Full name Your reference's full name Title Your reference's title within their organization Organization or facility name Your reference's organization or facility name Email address Your reference's email address Telephone number Your reference's telephone number Full name Your reference's full name Title Your reference's title within their organization Organization or facility name Your reference's organization or facility name Email address Your reference's email address Telephone number Your reference's telephone number Preferred Vendor Listing Would you like an email address added to your “Preferred Vendor” listing on our website www.maseniorcare.org? Yes No If yes, the email Would you like your company Facebook page added to your “Preferred Vendor” listing on our website? Yes No If yes, the link Would you like your company Twitter page added to your “Preferred Vendor” listing on our website? Yes No If yes, the link Services for Your Preferred Vendor Listing Using the chart below, please choose the services that best reflect your business. One Primary Service - None - Prosthetics and Diabetic ShoesAccountingAdult Foster CareAmbulance & Chair Car TransportationAudiologyAudiology,Dental Services,Optometry,PodiatryBankingBariatricBeds & MattressesCable TV ServicesCase Management ServicesClinical/Financial Compliance ServicesCollection ServicesCommunications and MarketingDental ServicesDental Services,Medical Services/Physicians/Nurse Practitioners/Physician AssistantsDesign & Construction ManagementDiagnostic & Laboratory ServicesDining Management ServicesDisease ManagementDraperies & LinensDurable Medical Equipment (DME)Durable Medical Equipment (DME),Oxygen/Respiratory Therapy ServicesEducation and TrainingElectronic Health RecordsEmergency PreparednessEmployee BenefitsEnergy & Utility ServicesEnteral Feeding ProductsEnvironmental Infection Control and Prevention Solutions & ServicesExecutive SearchFile and Record PurgingFinancial PlanningFire/Life Safety and Emergency ManagementFire/Life Safety ServicesFood Service Supplies & EquipmentFuneral & Cremation ServicesFurnitureGroup PurchasingHealthcare TechnologyHome Care/Supplemental StaffingHospiceHousekeeping & Laundry Services & SuppliesIncontinence SuppliesInfusion Therapy ServicesInsuranceInvestment ManagementIT ServicesLaundry Supplies & EquipmentLegal ServicesLogo'd ApparelManaged Care ServicesManagement/ConsultingMedicaid/Medicare Management ServicesMedical Services/Physicians/Nurse Practitioners/Physician AssistantsMedical Supplies/Services & EquipmentMedication Management & MonitoringMental Health ServicesMobile Modified Barium Swallow TestingMortgages/LendingOnline Staff SchedulingOptometryOrthoticsOrthotics & Prosthetics & Diabetic ShoesOxygen/Respiratory Therapy ServicesOzone & Laundry EquipmentPainting ContractorPatient LiftsPatient Safety Systems & Medical AlarmsPharmaceuticalsPharmacy ServicesPodiatryPrinting ServicesPrivacy CurtainsQuality ImprovementRadiology/Portable X-Ray/EKG/UltrasoundReal Estate ConsultingRecruitment & StaffingRehabilitation & Therapy ServicesRespiratory EquipmentSecuritySenior Care Organization (SCO)Social Work Consulting & StaffingSurvey Process ConsultationTechnology Services & Consulting/Software & EquipmentTelemedicineUniformsVascular ProceduresWater Safety and Water TreatmentWater/Fire Damage RestorationWound Care Management Begin typing a term to see options that best match your entry. Up to Three Secondary Services Prosthetics and Diabetic ShoesAccountingAdult Foster CareAmbulance & Chair Car TransportationAudiologyAudiology,Dental Services,Optometry,PodiatryBankingBariatricBeds & MattressesCable TV ServicesCase Management ServicesClinical/Financial Compliance ServicesCollection ServicesCommunications and MarketingDental ServicesDental Services,Medical Services/Physicians/Nurse Practitioners/Physician AssistantsDesign & Construction ManagementDiagnostic & Laboratory ServicesDining Management ServicesDisease ManagementDraperies & LinensDurable Medical Equipment (DME)Durable Medical Equipment (DME),Oxygen/Respiratory Therapy ServicesEducation and TrainingElectronic Health RecordsEmergency PreparednessEmployee BenefitsEnergy & Utility ServicesEnteral Feeding ProductsEnvironmental Infection Control and Prevention Solutions & ServicesExecutive SearchFile and Record PurgingFinancial PlanningFire/Life Safety and Emergency ManagementFire/Life Safety ServicesFood Service Supplies & EquipmentFuneral & Cremation ServicesFurnitureGroup PurchasingHealthcare TechnologyHome Care/Supplemental StaffingHospiceHousekeeping & Laundry Services & SuppliesIncontinence SuppliesInfusion Therapy ServicesInsuranceInvestment ManagementIT ServicesLaundry Supplies & EquipmentLegal ServicesLogo'd ApparelManaged Care ServicesManagement/ConsultingMedicaid/Medicare Management ServicesMedical Services/Physicians/Nurse Practitioners/Physician AssistantsMedical Supplies/Services & EquipmentMedication Management & MonitoringMental Health ServicesMobile Modified Barium Swallow TestingMortgages/LendingOnline Staff SchedulingOptometryOrthoticsOrthotics & Prosthetics & Diabetic ShoesOxygen/Respiratory Therapy ServicesOzone & Laundry EquipmentPainting ContractorPatient LiftsPatient Safety Systems & Medical AlarmsPharmaceuticalsPharmacy ServicesPodiatryPrinting ServicesPrivacy CurtainsQuality ImprovementRadiology/Portable X-Ray/EKG/UltrasoundReal Estate ConsultingRecruitment & StaffingRehabilitation & Therapy ServicesRespiratory EquipmentSecuritySenior Care Organization (SCO)Social Work Consulting & StaffingSurvey Process ConsultationTechnology Services & Consulting/Software & EquipmentTelemedicineUniformsVascular ProceduresWater Safety and Water TreatmentWater/Fire Damage RestorationWound Care Management Begin typing a term to see options that best match your entry. I certify that the information supplied above is true and accurate as of the date of this application. If accepted as an Associate Member, I pledge to abide by the Code of Ethics of the Association. I Accept