CAHSAH Provider Membership Application - Basic Organization Information (Page 1 of 5)

Welcome to the CAHSAH online membership application. The next several pages will allow you to apply for membership to CAHSAH by submitting your company information. You may choose to 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. Thank you for your continued support of CAHSAH.

Application Type:    New Member      Renewing Member  
Agency Name: 
Mailing Address:  City: 
State:  Zip Code: 
Telephone:  E-Mail: 
Web Address (opt):   

How many branches / additional licensed locations do you have (if none, please enter 0)?  

Has your agency or any other agency with which you have been affiliated ever had their CAHSAH membership or CAHSAH Home Care Aide Organization Certificate revoked or denied?   Yes     No

If Yes, please explain:

Conditions of Participation

  I Agree      I Do Not Agree