Missori Council For In-Homes Services Providers working together to advance home care.
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If you wish to print this form rather than fill it out electronically make sure you use the printable version.

Missouri Council For In-Home Services Membership Application
First Time Members: $300
Associate Membership: $150
Membership Renewals (based on annual hours served, see below)
0-5,000 Hours: $500
5,001-10,000 Hours: $550
10,001-50,000: $650
50,001-100,000: $800
100,000+ $1100

New Member:    Associate (Non-Provider):    Renewal:
First Name:
Last Name:
*Company Name:
Phone:
Fax:
*E-mail:
Street Address:
City:
Zip Code:
State/Province:
Parent Company:
(If applicable)
Location:
Parent Company CEO:
Director:
# Counties Served:
Annual delivery hours:
Branch offices - addresses/phone numbers:
Address:
Phone:
Address:
Services Provided
# of Years
Title XX:
Title XIX:
Title III:
Dept. Mental Health:
Private Pay:
Home Health:
Hospice:
Counseling:
Staffing:
Other:
Committees that you are interested in serving on:
Legislative:
Marketing/Ed.
By-Laws:
Membership:
Standards/Issue:
Other healthcare organizations to which you belong:
Contributions or gifts to the Missouri Council for In- Home Services (MCHS) are not tax deductible as charitable contributions for income tax purposes. However, they may be tax deductible as ordinary and necessary business expenses to restrictions imposed as a result of association lobby activities. MCHS estimates that the non-deductible portion of your dues - the portion allocated for lobbying - is 90%

You have two options for submitting this form:

1. Click the "Send" button below to send this form by email, you will then be contacted by MCHS regarding payment.

OR

2. Click the "Print" button below and mail this form with your payment to:

Missouri Council for In-Home Services
PO Box 1803
Jefferson City, MO 65102-1803
Thank You!
*This field is required.

 

Missouri Council for In-Home Services
PO Box Address 1803
Jefferson City MO 65102-1803
Phone: (573) 634-5272
Email: info@penman-winton.com
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Missouri Council for In-Home Services, PO Box Address 1803, Jefferson City, MO 65102-1803
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