Facility Membership Application

Required information is marked by an asterisk (*)

Organization Information:

Organization Name: *

Organization Address:

City, State Zip:*

County:

Phone: *

Fax:

Facility Website:

Administrator/Executive Director Name:

Administrator E-Mail: *

Title:

Owner/Operator Name:
(if different from above)

Owner/Operator E-Mail:
(if different from above)

Owner/Operator Address:

City, State Zip:
(if different from above)

Type of Organization:

Select... Skilled Nursing Assisted Living (Licensed) Enriched Housing Adult Home Assisted Living (Non-Licensed) Other

Please specify type of organization:

Sponsorship:

Select... Proprietary Voluntary Public

Operating Certificate Number:

Year Licensed:

Total Number of Beds:

Number of Licensed Beds:

Payment Method Preferred:

Select... Annual Semi-Annual Quarterly Monthly

Payment Agreement:

In accordance with Article IX – Dues and Assessments of the NYSHFA By-laws, dues shall be set by the Board by no later than the 15th of December of each year. A member may elect a monthly, quarterly, semi-annual or annual dues payment.

Dues are payable on the first day of the period chosen.

Membership automatically renews every January unless written notice is received indicating termination of membership.