Membership Application Form
Form Type
Organization Name:
*
Classification
Please Select
Private (For Profit)
Non-Profit
Corporation/Business
Educational Institution
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Website:
Select Membership Type:
*
Please Select
Business Partner
Voting Member - Home Care
Voting Member - DSL/LTC
Voting Member - Seniors Communities
If you are applying as the Head Office for multiple sites, please indicate how many sites fall under your organization’s umbrella.
Please provide info for each of your sites (Home Care)
Site Name
Address
Hours of Care Provided
# Of Employees
1
2
3
4
5
Please provide info for each of your sites (DSL/LTC)
Site Name
Address
Spaces/Beds
Hours of Home Care Provided (If applicable)
# of Employees
1
2
3
4
5
Please provide info for each of your sites - Seniors Community
Site Name
Address
Non DSL/LTC Spaces
DSL/LTC Spaces (If Applicable)
Hours of Home Care Provided (If applicable)
# of Employees
1
2
3
4
5
Add additional sites below if needed:
Total # of DSL Spaces
Total # of LTC Spaces
Total # of Seniors Community Spaces
Total Hours of Home Care provided in the last year
Total # of employees at your organization
Primary Contact
*
First Name
Last Name
Title:
*
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Additional Contacts: Please add any additional contacts from your organization i.e., all other individuals in your organization that may want to receive ACCA communications, newsletters, and updates.
Full Name
Title
Email
1
2
3
Logo:
*
Browse Files
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Choose a file
New members, please upload your organization's logo (png, jpeg or jpg)
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Organization Description:
*
New members, please include a short description of your organization and the services and/or products you provide.
Please verify that you are human
*
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