Member State Listing - National Association of Professional Geriatric ...

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AFFILIATE COMPANY MEMBERSHIP APPLICATION We are applying for Membership as an Affiliate Company Member at $495/year (see reverse side for description of Membership Category). A $25.00 application fee is required. Company Name Company Mailing Address (no P.O. Boxes, please) City State/Province Phone Fax Website Zip Company Contact Email Name of Primary Company Representative Email Name of 2nd Company Representative Email Name of 3rd Company Representative Email All representatives are eligible to receive Affiliate Company Membership Benefits. REQUIRED DOCUMENTATION Affiliate Company Web Listing Categories – Choose One: Advertising/Marketing Tools Business Support/Tools End-of-Life Services Financial Services CHAPTER MEMBERSHIP (INCLUDED) You will automatically be assigned to an NAPGCM Chapter, based on your business address (Chapters listed to the right). If you wish to join a different chapter, please indicate here:___________________________. Chapter membership is included in your dues. However, if you wish to join an additional chapter(s), cost for each additional chapter is $50. Please list additional chapters here: _______________________________________. � Healthcare Facilities � Healthcare Products/Services � Home Care Agencies � Legal Services Florida: Florida, Puerto Rico, Virgin Islands Mid-Atlantic: Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia Midwest: Illinois, Indiana, Iowa, Kansas, Kentucky, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin, Ontario New England: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, Quebec Country Electronic format is preferred for all the required documentation listed below. Please email to membership@napgcm.org 1. Please provide a 25-40 word description of the products or services your company offers. 2. Company Logo 3. Website Link � � � � 178 � Rehabilitation/Therapy � Relocation Services � Other (please List) ____________________________________ New Jersey New York Southeast: Alabama, Georgia, Mississippi, North Carolina, South Carolina, Tennessee South Central: Arkansas, Louisiana, Oklahoma, Texas Western Region: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, Wyoming, British Columbia
MEMBERSHIP CATEGORY DESCRIPTION AFFILIATE COMPANY – A non-voting industry supporter of NAPGCM who is not in the direct practice of care management, but has an interest in the field, including elder law attorneys, physicians, educators, researchers, employees of home health agencies, nursing homes, assisted living facilities, manufacturers or distributors of durable medical equipment or other products or services related to the care of elders. Membership may include up to three company representatives. Processing of your application will not begin until NAPGCM receives all documents. Please read and check each box to indicate agreement with these conditions: � � � � I certify that the statements herein are correct. NAPGCM Bylaws state that all members have equal rights and duties except that only members in Fellow or Certified Geriatric Care Manager category shall have the right to vote and hold elected office. No member shall have been convicted of, or have pled guilty or no contest to, a felony related to the professional activities of the member. Any member who is formally charged, through an indictment or similar process, with such a felony shall have their membership, and all rights and privileges thereof, automatically suspended pending resolution. A member formally charged as described above shall immediately notify the Association. I understand that my application will not be processed until payment is received by NAPGCM. I understand that the company contact information provided will be published in the Directory and on the NAPGCM website. A $25 application fee must be submitted with this application. Signature Printed Name Date Payment: � Check enclosed � VISA/MC/AMEX #________________________________________Exp.________________ Cardholder’s Name (please print) Signature How did you hear about NAPGCM? � Internet � Employer � Colleague � Conference � Other ____________ 179 Send your application to: NAPGCM Attention: Membership Coordinator 3275 West Ina Road, Suite 130 Tucson, AZ 85741 Phone 520.881.8008 Fax 520.325.7925 membership@napgcm.org
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Member State Listing napgcm 2011-20
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Page 129 and 130: Member State Listing napgcm 2011-20
Page 137 and 138: Affiliate company Listing napgcm 20
Page 143 and 144: B Member alphabetical Listing napgc
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Page 179: CATEGORIES OF MEMBERSHIP CERTIFIED
Page 183 and 184: CURRENT LISTING NAME: 3275 West Ina
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