CAHSAH Provider Membership Application - Basic Organization Information (Page 1 of 6)

NEW -- For your convenience, your organizational information will be pre-filled on your application as long as you are currently logged into the system. You may, of course, override any pre-filled information. If you do not have a login, you can simply fill out the application and submit it. If your information is not displayed below and you would like to log in at this time, please click here. If you are not logged in and would like to do so before completing and submitting your application, click here. Welcome to the CAHSAH online membership application. The next several pages will allow you to apply for membership to CAHSAH 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 for your continued support of CAHSAH.

*Application Type:	Renewing Member New Member

*Agency Name:
*Mailing Address:		*City:
*State:		*Zip Code:
*Telephone:		Fax Number:
E-Mail:		Web Address:
	Yes, we want to receive information via email only

Conditions of Participation
1. Provider Membership in CAHSAH is open to direct providers of health and supportive services and products in the home. 2. Adherence to CAHSAH Code of Ethics. 3. Membership benefits begin with receipt of payment and continue for one year. Only employees of the member entity may utilize member benefits. 4. Dues are calculated and based on total net revenues for the previous year. 5. Membership dues, set up fees and voluntary contributions are non-refundable. 6. Dues payments to CAHSAH are not deductible as a charitable contribution for federal income tax purposes. However, dues payments may be deductible as an ordinary and necessary business expense, subject to an exclusion for lobbying activity. Because a portion of your dues is used for lobbying by CAHSAH, 8% of your dues is not deductible for income tax purposes. I, as CEO, CFO or Executive Management, have read, understand and agree to abide by the Conditions of Participation. I further certify that I have accurately represented my agency's total revenues for the previous year.
I Agree I Do Not Agree

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.
*First Name:		*Last Name:
Billing Address
City
State		Zip

CAHSAH Provider Membership Application - Basic Organization Information (Page 1 of 6)

Credit Card Information