Application for Professional Membership

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

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Current Position

Name & Address of Current Employer

Current Employer

Address

City/Town

State/Province

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?

Names and Addresses of Two References

One should be from a Mass Senior Care Member, if known

Reference 1 Name

Reference 1 Phone Number

Reference 2 Name

Reference 2 Phone 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