*Facility Name:

*Address:

*Telephone:

Fax:

Website:

*Administrator:

*Email Address:

Mailing Address:

*Number of beds:

*Are you owned by a corporate entity?

If yes, number of facilities in Nevada?

Corporate name:

Corporate contact person:

Corporate contact telephone:

Corporate contact email:

CFO name:

CFO email:

Corporate fax:

Corporate mailing address:

MEMBERSHIP CATEGORY: SKILLED NURSING FACILITY

Facility Members pay dues, vote, and are eligible to hold Association office. Any facility licensed by the State of Nevada shall be eligible to make application for Facility membership in the Association.

CERTIFICATION

I certify that the information submitted in this application is true, complete, and correct to the best of my knowledge.

*Electronic Signature - Initial Here To Certify:

*Print name:

*Date:

MEMBERSHIP IN THE NEVADA HEALTH CARE ASSOCIATION INCLUDES THE FOLLOWING:

• Political Representation
• UPDATE Newsletter
• Listing as a Trade Member in the NHCA Website Directory
• First opportunity to sponsor education and convention events
• Discounted Registration Fee for Annual Convention
• AHCA Membership

Click SUBMIT below when the form is complete.