EmailMe Form - Membership Application Request

Name *

First Last

Title *

Organization *

Organization Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

Type of membership interested in: *

*Assisted living membership requires you to have applied for an AL license or have a current AL license with MDH.

**Home care membership requires you to have applied for a Basic or Comprehensive Home Care license or have a current Basic or Comprehensive license with MDH.