Better Living for Seniors Hillsborough
www.BLFSA.com
2016 New Membership and Membership Renewal Invoice
Pick Category Listing (only one per membership, added categories extra, see below)
Accountants Geriatric Care Mgt. Managed Care Organizations
Alzheimer’s/Dementia Support Guardian/Advocate Misc. Info/Product/Services
Assisted Living Facilities Home Care (indicate types) Pharmacy
Churches and Religious Support Home Health non-medical Real Estate/Relocation/Estate Svcs.
Community Service Organizations Homemaker & Companion Retirement Communities(indicate type)
Durable Medical/Medical Supplies Medicare/Medicaid eligible CCRC
Elder Law/Estate Planning Nurse Registry Independent Living
Financial Planning Home Repair/Remodel/Maint. Subsidized apartments
Food Services Hospice Services Skilled Nursing Facilities
Congregate dining Insurance Professionals Social /Recreational Services
Home delivered meals Individual Social Worker/Case Manager
Printing/Publishing Services Law Enforcement Therapy Services
Funeral Planning Medical Professionals Veteran’s Support
Company/Agency/Individual NameName/Business:
Contact: / Phone:
Title: / Fax:
Credentials,licenses,certificates and/or designations:
Address:
Email: / Website:
How many years in business
Have you ever had your license suspended or revoked? Yes No
If your business has multiple members, indicate name of Primary member:
Secondary Member Name and Email (if applicable - see fee schedule)
Additional Members Name and Email (if applicable – see fee schedule)
Briefly describe the benefits you can offer Hillsborough County Seniors:
Areas of Interest Networking/Public Relations/Communication Membership Education,Outreach,Advocacy Fundraising
DESCRIPTION / Primary member / 2nd member / Add’l member
Better Living for Seniors Coalition - Membership Dues
(January-December 2016)
Individual Membership (No business affiliation)* / $35.00
Non-profit Agency/Organization/Government
Primary member $35, Second member $18, Add’l members $10 / $35.00 / $18.00 / $10.00
For Profit Firm/Business
Primary member $50, Second member $25, Add’l members $10
(Please provide add’l member’s name, title, phone & email on back of form) / $50.00 / $25.00 / $10.00
Payable upon receipt. Please make check payable to “BLS Hillsborough” and send payment to:
BLS c/o Senior Connection Center
8928 Brittany Way
Tampa, FL 33619 / $
TOTAL
PAYMENT / $
TOTAL PAYMENT / $
TOTAL PAYMENT
*Individual Membership indicates there will be no Business affiliation or opportunity to distribute literature or promote any business interest.
**BLS or WCFAAA reserves the right to deny, suspend or discontinue membership for any organization, business or individual that engages in conduct considered detrimental to the integrity of BLFSA or their own profession, based on the Board’s discretion.
Questions? Visit www.BLFSA.com and click on the Contact Us link.