CAHSAH Affiliate Application - Basic Organization Information (Page 1)

Welcome to the CAHSAH online Affiliate application. Affiliate, and Associate dues are $750 per year. The next several pages will allow you to apply for CAHSAH benefits and either pay online with a credit card or check by mail. If you choose to pay by check, this process will create an invoice which can be included with your check. If you choose to pay by credit card, you will be directed to a secure credit card page which will ask for your credit card information. Fields marked with an * are required fields. Thank you very much for using this system.

Affiliate Type:	Affiliate (consultant / vendor) Associate (out-of-state provider)
Application Type:	Renewing New

Company Name:
Key Contact:		Title:
Company Address:		City:
State:		Zip Code:
Telephone:		Fax Number:
E-Mail:		Web Address:
	Yes, we want to receive information via email only
Payment Method:	Mail In Check Online Credit Card

Credit Card Information
Please enter your credit card billing information below. If your billing address is different than your company mailing address please make changes below. You will not be asked for the credit card number or expiration date until you have gone to the secure payment site.
Cardholder Name
Billing Address
City
State		Zip


Conditions of Participation
By accessing and submitting this CAHSAH application on-line, I agree to be bound by all terms and conditions of use of CAHSAH's website and contained in this on-line application, as of the time of my access and use. I understand affiliation with CAHSAH is open to organizations providing services and products to the home care industry, out-of-state home care agencies, registries and referral agencies and individuals. I certify the organization identified above is an Affiliate, meaning: Out of State Providers. Home care service providers in the categories identified below provide services and products in clients' homes through persons, the majority of whom are employees of the provider or provider entity outside the state of California. - Medicare Certified Home Health Providers - Licensed Home Care Providers - Hospices - Home Care Aide Organizations - Home Infusion Pharmacy Companies - Home Medical Equipment Providers - Interdisciplinary Professional Services Vendors. Organizations providing services and products to the home care industry Registries and referral agencies. Organizations which do not employ the workers who provide services in clients' homes, such as nurse registries, employment agencies and domestic referral agencies. Individuals. Volunteers, board members, and/or individual home care staff members from a member organization; academicians/researchers; and other interested parties. I understand that affiliate benefits begin upon the receipt of payment of dues and continue for one year. Affiliate dues, set up fees and voluntary contributions are non-refundable. Dues payments to CAHSAH are not deductible as a charitable contribution for federal or state income tax purposes. However, dues payments may be deductible as ordinary business expenses, subject to exclusion for lobbying activities. Because a portion of your dues is used for lobbying by CAHSAH, 14% of your dues is not deductible for income tax purposes. By indicating my acceptance below, I confirm that I am the CEO, CFO or an executive of the organization identified above, I represent that the information in the affiliate application is accurate and correct and I have read and understand the CAHSAH dues policy. I confirm my agreement with the foregoing terms and conditions of CAHSAH affiliation and the accuracy of the information submitted by indicating my acceptance.
I Agree I Do Not Agree