Membership Application

Free Standing Assisted Living Facility

Author Information
The information in this section is about the person filling out this form. If you are not the main contact for the company/facility, a field is provided for information regarding the main contact.
Your Name:	*
Your Email:	*
Your Phone:	*
I am not the Main Contact for this Company/Facility
Main Contact Name:
Main Contact Email:
Main Contact Phone:
Facility Information
Facility:	*
Address:	*

City, State, Zip:	, *
Phone:	*
Fax:

Executive Director:	*
Email:	*
Regional Director of Operations:
Email:
Phone:
License Number:
Assisted Living Licensed Level of Care:
Number of Assisted Living Beds:	*
Owner Information
Company:	*
Address:	*

City, State, Zip:	, *
Phone:	*
Fax:

Contact Name:	*
Email:	*
Is the Facility Part of a Mulit-Facility Company?:	Yes No If yes, you may be eligible for a discount. Please call 410-381-1176 X232 for more information.
If yes, list all Maryland Facilities:
	Please note: Each facility must apply for membership on a separate membership application.
Billing Information
Billing Information is the Same as Facility Information

Contact Name:	*
Title:
Address:	*

City, State, Zip:	, *
Phone:	*
Fax:
Email:	*
Additional Contacts	Max 5 Contacts
Name:
Title/Department:
Email:
Phone:
Cellphone:
Same as Facility
Address:

City, State, Zip:	,

Name:
Title/Department:
Email:
Phone:
Cellphone:
Same as Facility
Address:

City, State, Zip:	,

Name:
Title/Department:
Email:
Phone:
Cellphone:
Same as Facility
Address:

City, State, Zip:	,

Name:
Title/Department:
Email:
Phone:
Cellphone:
Same as Facility
Address:

City, State, Zip:	,

Name:
Title/Department:
Email:
Phone:
Cellphone:
Same as Facility
Address:

City, State, Zip:	,

Please Provide Information on Group Purchasing Programs:
	Insurance Food
I Prefer a Paperless Membership Paperless Membership means that all appropriate materials will be e-mailed or put on the LifeSpan Website for your review.

Dues Information
	For Profit
	Facility is Under Development or Under Construction
	Expected Completion Date:
LifeSpan Annual Dues:
Total Amount:
Pay This Amount:

	Please Bill me

LifeSpan Network
10280 Old Columbia Road #220
Columbia, Maryland 21046
Phone: 410-381-1176
Fax: 410-381-0240