DAHCC Membership Application for Credit Card Users Please complete the information below. If you wish to pay by check, use the mail in form for submitting your application and payment by mail. Please enable JavaScript in your browser to complete this form.Organization *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Website / URLMembership TypePlease choose oneNewly Licensed MembershipPending Licensure MembershipSingle License Membership (Bronze-Silver-Gold-Platinum)Multi-Agency License Membership (Bronze-Silver-Gold-Platinum)Individual MembershipSponsor MembershipProvider Agency Licensure TypePlease choose oneHHAS (Home Health/Skilled)HHAO (Home Health Aide Only)HospicePASA (Personal Assistance Service AgencyAllied (Not Home Care or Hospice Provider)Membership Type & Payment PlansPending LicensedAnnual (pay in full by January 15th) – $ 400.00Annual (pay in full after January 15th) – $ 500.00Newly Licensed (Licensed less than 12 months)Annual (pay in full by January 15th) – $ 400.00Annual (pay in full after January 15th) – $ 500.00Bronze Single License: Annual Revenue less than $1 millionAnnual (pay in full by January 15th) – $ 600.00Annual (pay in full by January 15th) – $ 600.00Annual (pay in full after January 15th) – $ 750.00Silver Single License: Annual Revenue $1-3 millionAnnual (pay in full by January 15th) – $ 1,100.00Annual (pay in full by January 15th) – $ 1,100.00Annual (pay in full after January 15th) – $ 1,250.00Gold Single License: Annual Revenue $3-6 millionAnnual (pay in full by January 15th) – $ 1,600.00Annual (pay in full by January 15th) – $ 1,600.00Annual (pay in full after January 15th) – $ 1,750.00Platinum Single License: Annual Revenue greater than $6 millionAnnual (pay in full by January 15th) – $ 2,100.00Annual (pay in full by January 15th) – $ 2,100.00Annual (pay in full after January 15th) – $ 2,250.00Bronze Multi License: Annual Revenue less than $1 millionAnnual (pay in full by January 15th) – $ 600.00Annual (pay in full by January 15th) – $ 600.00Annual (pay in full after January 15th) – $ 750.00Silver Multi License: Annual Revenue $1-3 millionAnnual (pay in full by January 15th) – $ 1,100.00Annual (pay in full by January 15th) – $ 1,100.00Annual (pay in full after January 15th) – $ 1,250.00Gold Multi License: Annual Revenue $3-6 millionAnnual (pay in full by January 15th) – $ 1,600.00Annual (pay in full by January 15th) – $ 1,600.00Annual (pay in full after January 15th) – $ 1,750.00Platinum Multi License: Annual Revenue greater than $6 millionAnnual (pay in full by January 15th) – $ 2,100.00Annual (pay in full by January 15th) – $ 2,100.00Annual (pay in full after January 15th) – $ 2,250.00Multi-Licensed Additional FeeSame Ownership licenses combined = Revenue Tier + additional fee for each additional license (excluding your primary membership license)Enter the number of additional licenses (Excluding your primary membership license) *Annual (if paid in full by January 15th)$350 per license | Enter the total amount for all licenses (except your primary) Annual (if paid in full after January 15th)$500 per license | Enter the total amount for all licenses (except your primary) Please provide the following information and use the upload option below:Include Agency Name, Contact Name (First and Last Name), Address, Email, PhonePlease upload a list all additional licenses here: * Click or drag a file to this area to upload. Individual MembershipSingle individual with interest in health care, not affiliated w/a licensed provider agency. Examples: sole proprietor, contractor, consultant, etc., with no employees. Choose a payment plan below.Individual Membership Payment PlanAnnual (pay in full by January 15th) – $ 300.00Annual (pay in full after January 15th) – $ 350.00Sponsor MembershipAssociations, Manufacturers, Vendors of Products or Services, Hospitals, LTC Facilities, Staffing Agencies, etc., not licensed at PASA, Aide-Only, Skilled, Hospice Choose a payment plan and if you would like to advertise below. Sponsor Payment PlanAnnual (pay in full by January 15th) – $ 850.00Annual (pay in full after January 15th) – $ 1,000.00Company advertisement on website if offering member discount add – $ 250.00Company advertisement on website with no offer of member discount add – $ 500.00Agency Primary RepresentativeProvide the information as you wish it to be listed:Agency Name *Name *FirstLastEmail *Phone *Agency Alternate RepresentativeProvide the information for your alternate as you wish it to be listed:Alternate Representative NameFirstLastAlternate Representative EmailAlternate Representative PhoneShare the Knowledge: Members may add as many staff as you wish per paid member license. Multi-licensed Members: If you have remote support office staff employed by your company at a non-licensed location and wish for them to be included in DAHCC communications, you may include them as staff of your primary license membership.Share the Knowledge File Upload Click or drag a file to this area to upload. Print Your Name *(as acknowledgement all information is accurate)Today's Date *Comments or Questions:PAYMENT INFORMATIONTotal Amount$ 0.00Credit Card *CardName on CardSubmit
