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	Associate Adult Day Services Membership

Organization & Primary Contact Information:*

Organization/Company:
Address:
City, State, Zip:
Phone:
Fax:
Website:
Primary Contact (Mr./Ms.) First & Last Name:
Primary Contact Title:
Primary Contact Phone:
Primary Contact Email:

Type of Ownership*

	Proprietary
	Proprietary - privately owned
	Proprietary - publicly traded
	S-Corporation

If you have a parent corporation/owner other than that listed above, please provide the following:

Other Contacts from Your Organization

Dues Contact Name (if different from primary):
Dues Contact Title:
Dues Contact Email:
Directory Update Contact Name (if different from primary):
Directory Update Contact Title:
Directory Update Contact Email:

Please list any other team members you wish to receive communications from LeadingAge Minnesota:

	About Your Organization

Is your program licensed?

	No - unlicensed, under 5 people served
	Yes

If licensed, enter the capacity for this program:

	I understand that membership is conditional upon approval by the LeadingAge Minnesota Board of Directors and that before becoming a member I must remit the necessary dues.

7.	Electronic Signature* (Please type in your name)

	This category of membership provides full member benefits, including the ability to vote, hold office and serve as a Director. Please submit dues to: LeadingAge Minnesota 3001 Broadway Street NE, Suite 300 Minneapolis, MN 55413 651.645.0002 (FAX) membership@leadingagemn.org