KACE Membership Application

PLEASE SEND THE KACE ADMINISTRATOR'S JOURNAL AND ANY OTHER KACE MAIL TO:
MY FACILITY _______     MY RESIDENCE _______
Do you wish to receive a new KACE Membership Certificate?  Yes ____  No ____

YOUR NAME __________________________________________

NAME OF ADULT CARE FACILITY _____________________________________

FAC. PHONE NUMBER ____________________ FAC. FAX NUMBER ___________________

FAC. ADDRESS ________________________________

FAC. CITY/ZIP _____________________________ FAC. COUNTY _________________

FAC. SURVEY REGION NUMBER __________

E-MAIL ADDRESS __________________________ Home _____ Facility ____

___________________________________________________________________
  YOUR HOME ADDRESS, CITY, STATE, ZIP

YOUR HOME PHONE NUMBER ______________________

YOUR ADMINISTRATOR'S LICENSE NUMBER ____________________
NUMBER OF YEARS YOU HAVE BEEN A MEMBER OF KPNHAA/KACE _________

Dues Information

____ $175.00 for all Licensed Administrators/Operators 
____ $145.00 for all others interested in quality resident care.

Payment Method:  Check ______ Visa ____ Mastercard _____ If paying by credit card, please indicate the following:

___________________________________________________________________
Account Number                   Expiration Date                     Signature

"I give permission to KACE/Tanner-Foster to send my facility or me information on Association services, events and activities, by mail, FAX, e-mail, or other means, as it deems appropriate."

Your Signature ___________________________________
 

Print and return to: KACE, 3601 SW 29th, Suite #202, Topeka, KS 66614