LeadingAge Minnesota - Business Partner Membership Application
Time Elapsed:
0
minutes
Time Remaining:
0
minutes
Total Time:
0
minutes
Anonymous Login Code:
Code Entry Page
Save this code which is required to update your response at a later time.
Page 1 of 1
Business Partner Membership
1.
Company & Primary Contact Information:
*
Company:
Address:
City, State, Zip:
Phone:
Fax:
Website:
Primary Contact First & Last Name:
Primary Contact Title:
Primary Contact Phone:
Primary Contact Email:
Other Contacts from Your Company
2.
Dues Contact
*
Name:
Title:
Email:
3.
Name Listed in Online Directory
*
Name:
Title:
Email:
4.
Please list any other team members you wish to receive communications from LeadingAge Minnesota:
Name:
Title:
Email:
Name:
Title:
Email:
5.
Number of Employees:
6.
How did you hear about LeadingAge Minnesota and what are your primary interests in membership?
7.
Provide a brief description of your business (2-3 sentences). This will be displayed on our website for members to view.
8.
Product/Service Category
*
Please select one primary category and, if applicable, check up to two secondary categories. LeadingAge Minnesota reserves the right to determine appropriate use of additional business categories.
Accountants
Apparel
Architects
Assistive Technology
Audio/Video Systems
Bariatric Equipment
Bariatric Needs
Bathing
Call Systems
Computer Equipment/Software
Construction Management/Contractors
Consultants/Independent Contractors
Consultants/Marketing
Dietary Equipment and Design
Digital Health
Durable Medical Equipment
eHealth Records
Employee Recognition
Employer Services/Human Resources
Environmental Services
Exterior Restoration
Financial Investment Services
Food
Food Service Management
Furnishings/Interiors
Health Care Services Network
Health Care Service Providers
Home Health Care and Hospice
Incontinence
Insurance
Interior Design
IT Solutions
Laundry Outsourcing
Laundry Services
Legal Services
Lifts
Maintenance Supplies
Management Services
MDS/RUGS Software
Medical Billing/Collections
Medical Laboratory
Medical Supplies
Network Systems
Nutritional Supplements
Office Equipment
Office Supplies
Oxygen Services
Pharmacy Services
Printing/Promotional
Purchasing Services
Quality Improvement/Management
Real Estate Development
Rehabilitation Services
Retirement Services
Security Solutions
Shredding Documents
Skin Care
Surfaces
Telecommunications
Television Programming/Private Cable
Textiles
Therapeutic Services
Training and Education
Transportation
Unemployment Services
Utility Services
Wellness & Exercise
Wound Care
X-Ray/Imaging Services
Other, please specify
9.
Please indicate your primary category from #6 list above.
*
10.
I understand that membership is conditional upon remittance of the necessary dues. (Please select one.)
*
Please email me an invoice to pay by check.
Please email me a payment link to pay by credit card.
11.
Electronic Signature & Date
*
(Please type in your name and date)