Criteria "To be eligible for Professional Membership in the Massachusetts Senior Care Association, an individual must NOT qualify for either facility membership or associate membership." 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 Email Address Current Position Name & Address of Current Employer Current Employer Address of Current Employer 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 Current Employer Phone Number Type of Business How Does Your Profession Relate to Long Term Health Care? Have You Had a Prior Relationship with the Massachusetts Senior Care Association or a Member Facility? Yes No If Yes, in What Capacity Was Your Relationship or Which Facility? References References (minimum of two) - One should be from a Mass Senior Care Member, if known. 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 I certify that the information supplied above is true and accurate as of the date of this application. If accepted as a Professional Member, I pledge to abide by the Code of Ethics of the Association. I Accept