Date Name of Facility Telephone Address Information Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Fax Number Facility Website Number of Beds Assisted Living Units Independent Living Units Other Other Number of Beds Total Beds Apartment Types Studio One Bedroom Two Bedroom Monthly Fee Range Minimum $ Maximum $ Income Subsidies (other than G.A.F.C.)? Yes No Is your Residence a Special Care Residence or have Special Care Residence units as defined by the Executive Office of Elder Affairs? Y or N Yes No Date Acquired Year of Original Certification Year of Original Certification: Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Do you or your organization own any other facilities in Massachusetts? Type of Ownership Proprietary Non-Profit Legal Ownership Proprietorship Partnership Corporation Names of Owner, Partners, Members of Corporation Name of Administrator/Executive Director Administrator Email Names of Person (state position) who will represent the facility in the Association if not Administrator References References (minimum of two) - must be a physician, hospital or other nursing home and/or commercial or banking and finance (for organizations, please list name of individual to contact). Full name Title Organization or facility name Email address Telephone number Operations Full name Your reference's full name Title Your reference's title within their organization Organization or facility name Your reference's organization or facility name Email address Your reference's email address Telephone number Your reference's telephone number Full name Your reference's full name Title Your reference's title within their organization Organization or facility name Your reference's organization or facility name Email address Your reference's email address Telephone number Your reference's telephone number Agreement If accepted to membership, I pledge, on behalf of the facility, to abide by the laws, bylaws, and professional ethics and standards of the Massachusetts Senior Care Association. In the event of termination of membership, it is hereby agreed that any and all certificates and other indications of membership will be promptly surrendered. I Accept