Assisted Living Provider Membership Application

Membership Fee for Licensed Homes and Centers:
11 Beds or more = $29 per bed

Organization
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Email
Website
U.S Congressional District#
AZ Legislative District#:
Referred)By:
CEO and/or Manager (Main Point of Contact)
Name
First
Title
Address (if different)
Address City State / Province / Region ZIP / Postal Code Country
Phone (if different):
Fax (if different):
Email (if different):
Billing Contact (if different from main contact above)
Name
First
Title
Address
Address (if different) City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Email
Is billing contact for a multiple campus facility/corporation?
- Yes
- No
Name of Corporation
Community Composition
# Total Employees
FT
PT
Total # of Assisted Living Licensed Beds:*
Please enter a number greater than or equal to 11.
Level of care:
Supervisory
Personal
Directed Accept ALTCS?
- Yes
- No
Is the community under development/construction?
- Yes
- No
Being Date:
Est. End Date:
Assisted Living Provider Membership
Price: $0.00
Total
$0.00
Credit Card
Card Details
Cardholder Name

*Dues payments to Arizona ALFA are not tax deductible as charitable contributions for federal income tax purposes. Contributions or gifts to Arizona ALFA may be tax-‐deductible as ordinary and necessary business expenses (15% of dues fee is non-deductible as lobbying expenses).

The member maintains Worker Compensation as required by law;
The member maintains professional liability insurance;
The member follows a non-‐discrimination policy in the hiring of employees and the admission of residents as required by law.

The member subscribes to continuing education and training of its employees to better serve residents;
The member conducts employment reference checks on its employees prior to employment;
The member will ensure that each direct care employee is properly fingerprinted;
The member will create a written service plan for each resident stating the level of care to be provided;
The member operates the home/center in a fiscally responsible manner;
The property maintains and displays a valid operating license issued from the Office of Assisted Living Licensure, Department of Health Services, and State of Arizona.