Please list the LTC facilities at which you work. Please include: street address, city, state and zip code. Put each facility on a separate line.
Send Payment After you submit this membership dues form, you will be taken to a payment page where you can choose to pay your membership dues with a credit card using PayPal's secure onine system, or you may elect to send in your payment via fax or U.S. mail. Please be sure to click the submit button below.