Ready to Join KSLA? It's easy! Just complete the web form below. Provider Member Application Community Name*Contact Person's Name & Title* First Last Title E-Mail Address*Office Phone Number*Cell Phone NumberFax NumberCommunity Website* Please Upload Your Company Logo Here*Accepted file types: jpg, png.Community Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County In Which Community is Located*Is This the Mailing Address?*YesNoMailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner's Name* First Last Owner's Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner's Office Phone Number*Owner's Cell Phone NumberOwner's Fax NumberOwner's E-Mail Address* Is Your Community Currently Under Construction or Not Yet Open?*YesNoUpon Completion, How Many Assisted Living Units will Your Community Have?Upon Completion, How Many Personal Care Beds will Your Community Have?Upon Completion, How Many Memory Care Beds will Your Community Have?Upon Completion, How Many Independent Living Apartments will Your Community Have?Annual Dues - Under Construction Price: $250.00 KSLA Annual Dues Investment for Assisted Living Community Living Units, Personal Care Home Beds, or Independent Living Apartments that are currently under construction or not yet in operation. This amount will be applied to your Dues Investment once in operation. Does Your Community Have Assisted Living Units?*YesNoHow Many Assisted Living Units are there in your Community?How Many of These Assisted Living Units Are Memory Care Units?Annual Assisted Living Dues Investment for Communities with 1-12 Living UnitsIf there are 12 Living Units or fewer, the minimum dues are $300 per year. Price: $300.00 Annual Dues Investment for Assisted Living Communities with 13-99 Living UnitsDues for communities with 13-99 Living Units are $24 per Living Unit per year. Price: $24.00 Quantity: Annual Assisted Living Dues Investment for Communities with 100+ Living UnitsIf there are 100 Living Units or more, the maximum dues are $2,400 per year. Price: $2,400.00 Does Your Community Have Personal Care Beds?*YesNoHow Many Personal Care Beds are there in your Community?How Many of These Personal Care Beds are Memory Care Beds?Annual Dues Investment for Personal Care BedsOnly Personal Care Homes Offering Apartment-Style Living Arrangements are Eligible for Membership. Price: $18.00 Quantity: Does Your Community Have Independent Living Living Apartments?*YesNoHow Many Independent Living Apartments are there in your Community?Annual Dues Investment for Communities with 1-50 Independent Living ApartmentsAnnual Dues for Independent Living Apartments are $10 per Independent Living Apartment, up to 50 Independent Living Apartments. Price: $10.00 Quantity: Annual Dues Investment for Communities with 51+ Independent Living Apartments Price: $500.00 The Annual Dues Investment for Independent Living Apartments is $500 per year for communities with over 50 Independent Living Apartments.Total Dues Investment $0.00 How Will You Pay Your Membership Dues?*I'll Mail a Check - please send me an invoiceI'll Pay By Credit Card NowPlease Enter Your Credit Card Information Here American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name
KSLA@kentuckyseniorliving.org 133 Evergreen Road Suite 212 Louisville, KY 40243 502-938-5102 Fax: 502.805.0589
