2022-23 Membership Application Membership Year: June 1, 2022 - May 31, 2023 Question Title * 1. Contact Information Name: Email: Agency/Company: Website: OK Question Title * 2. Please select type(s) that apply to your agency: Medicare-Certified Home Health Agency Medicare-Certified Hospice State Licensed Home Care Agency Registered Homemaker/Personal Care Associate/Allied (provides goods/services but not direct care in the home) Individual/Sole Proprietor (appropriate for self-employed consultants) OK NEXT