Membership Application

APPLICATION FOR KHCA/KCAL MEMBERSHIP

Organization Name:  

Address:  

City:      Zip:     County:

Telephone #:       Fax #: 

Email:   

Website: 


Administrator/Operator/Executive Director:

First Name:    Last Name:




                                                          Total Beds:

                                                            NF Beds:

                                                     ALF/RHCF Beds:


Name and address of principal owner(s), president, or board chairman:

First Name:     Last Name:   

Address:   

City:  State:  Zip: