LeadingAge Minnesota - Not-for-Profit Adult Day Membership Application
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Not-for-Profit Adult Day Services Membership
1.
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:
2.
Type of Ownership
*
Governmental - city
Governmental - county
Governmental - hospital district
Governmental - other
Governmental - state
Governmental - VA
Not for profit - fraternal
Not for profit - other
Not for profit - private foundation
Not for profit - religious
3.
If you have a parent corporation/owner other than that listed above, please provide the following:
Parent Organization Name:
Address:
City, State, Zip:
Phone:
Fax:
Website:
Contact Name, Title & Email:
4.
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:
5.
Please list any other team members you wish to receive communications from LeadingAge Minnesota:
Name:
Title:
Email:
Name:
Title:
Email:
Name:
Title:
Email:
Name:
Title:
Email:
About Your Organization
6.
Is your program licensed?
*
No - unlicensed, under 5 people served
Yes
If licensed, enter the capacity for this program:
7.
Please enter all (not just net) revenue specific to this site.
$________________2021 gross revenue
8.
Please enter all (not just net) revenue specific to this site.
$________________2021 gross revenue
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.
9.
Electronic Signature
*
(Please type in your name)