PHONE/FAX 501-941-2075
MEMBERSHIP APPLICATION
FACILITY NAME:
ADMINISTRATOR/CONTACT PERSON:
ADDRESS:
MAILING ADDRESS (if different):
CITY: STATE: ZIP:
TELEPHONE NUMBER/S: FAX NUMBER:
EMAIL ADDRESS: WEBSITE:
LICENSED BEDS: DATE LICENSED:
DATE OF FACILITY CONSTRUCTION OR LAST MAJOR RENOVATION:
TYPE OF OWNERSHIP:
sole proprietor¨ partnership¨ private corporation¨ private not-for-profit¨ public¨
church¨ other¨
RELATED EXPERIENCE/TRAINING OF OWNER/ADMINISTRATOR:
Please complete and mail or fax to the address/fax number listed above. Association dues are $3.00/licensed bed/month.