2022 Membership Application

$700 per state association

* Association Name:

* Contact Name:

* Title:

* Association Address:

* City:

* State:

* Zip:

* Phone:

* Email:

* Website:

* Association Annual Budget:

* # Members:

* # Association Staff:

Other Memberships:

* Payment Method:
Credit Card
Check

If you are paying by credit card, click "Submit" below, "Check Out" on the next page, and then enter credit card information on the next page. Click "Enter credit care information and pay now" and then "Process My Order."

If you are paying by check, click "Submit" below and "Check Out" on the next page. Then select "Submit Order without Payment" and then "Process My Order." Mail your check to Council of State Home Care & Hospice Associations, c/o PHA, 600 N. 12th Street, Suite 200, Lemoyne, PA 17043.