Membership Application

Please tell us about yourself and your company/facilities:
Please fill in each box.

Name of Business:

Contact Person and Title:

Address:

City:

State:

Zip:

Phone:

Fax:

E-mail:

www.

Please check the type of membership you represent:

Certified Assisted Living Providers and Licensed Residential Care Facilities: A facility that provides assisted living services. Provide a list of these communities. Also mail a copy of the certificate of occupancy or certification evidencing resident capacity. If a multi-facility provider, all facilities must join individually.

$12.00 per resident capacity. Minimum annual dues of $200. If a multi-facility provider, all facilities must join individually. Please enter the number of residents you are certified for.

Example: 30 units (residents) x $12.00 = $360 amount due.
Minimum due is $200 if resident total is less than 20 units.

Non-Providers: Independent living, nursing homes, hospitals, and any other senior housing/service/care alternatives, including developers. Flat fee based on resident capacity. Flat fee based on resident capacity.

Please check the box that best describes your facility.

$250    20 or fewer residents

$500    21 - 74 residents

$750    75 or more residents

Associate Members: Individuals or organizations that provide services to the assisted living industry, such as architects, insurers, attorneys and lenders.

$300 Flat fee

Government/Other: This category includes any government agency, area agency on aging, full-time student and senior citizens.

$50 Flat fee

It's easy to join IALA:
Please check one of the following:

	I would like to apply for membership with IALA via email
	I prefer to print off the application and mail with membership fee and if applicable a copy of Certificate of Occupancy.
	Please call me at my telephone number listed above for additional information
	Please mail me a "Prospective Membership Packet"

To apply via email complete the membership application and forward by clicking on the "submit" button. If you select to submit via email an invoice will be generated and mailed to you. Upon receipt of your dues payment all the benefits of IALA will be yours!

Annual membership fees run January 1 through December 31. Membership dues will be pro-rated to the first of the month in which the application is received.

To confirm your membership dues amount call the IALA office at 515-278-8700.

To submit application with payment, please make check payable to Iowa Assisted Living Association and mail to:

Iowa Assisted Living Association
9001 Hickman Road, Suite 220
Des Moines, Iowa 50322

Thank you for your consideration!