Associate Membership Application

Required information is marked by an asterisk (*)

Organization Information:

Organization Name: *

Address:

City, State Zip:*

Phone: *

Fax:

Company Website:

Organization Representative:

Representative E-Mail Address: *

Title:

Representative Extension:

Facility/Business Name:
(Skilled Nursing Facility or other Business Reference)

Phone:

Contact Person:

Description/Services:

Please send a copy of the most recent Annual Report or copies of promotional materials to the address listed below.

$800.00 Annual Membership
(January - December)

$575.00 Pro-Rated
(Applications received after July 1st, covers through December 31st)

Please send payment to:

Associate Member Program
NYSHFA
33 Elk Street, Suite 300
Albany, NY 12207-1010