Membership Application Form
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
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
1
2
3
4
5
Please provide info for each of your sites (DSL/LTC)
Site Name
Address
Spaces/Beds
1
2
3
4
5
Add additional sites below if needed:
Total Hours of Home Care provided in the last year
Total # of DSL Spaces
Total # of LTC Spaces
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
Drag and drop files here
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.
Payment
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Business Partner
$
1,545.00
CAD
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
CAD
Credit Card
First Name
Last Name
Credit Card Number
Security Code
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
Expiration Year
Please verify that you are human
*
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