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Facility Membership Application

Fill out the form below to complete your MALA Facility Membership Application.

Prefer to fill it out by hand and mail in a check? Click “Download PDF” to download a printable form.

Download PDF
Facility Membership Application

Facility Information

If more than one facility is owned, but less than five total, please submit a separate form for each facility

DHSS Region – Refer to map below

DHSS Region Map
What Region is the Facility Located?

Contact Information

Facility Licensure by Department of Health & Senior Services
Are you also licensed by the Department of Mental Health?
Required if 50% or more of residents have a mental illness diagnosis OR one resident or more with a mental retardation diagnosis.
Do you participate in the Personal Care Program (Medicaid)?

Annual Membership Dues

Do you own more than five (5) or more licensed facilities in Missouri?
General Members:

For persons/entities owning less than five (5) licensed facilities in Missouri:

Number of DHSS Licensed Beds: ___ x $6 = ___ plus $200 base rate = $_____

(not to exceed grand total of $750 per facility)

x $6 =

plus $200 base rate =
(not to exceed grand total of $750 per facility)
Corporate Members:

For persons/entities owning five (5) or more licensed facilities in Missouri:

Number of DHSS Licensed Beds:____ x 4 = ____ plus $1150 base rate = $____

(not to exceed grand total of $10,500)

x $4 =

plus $1,150 base rate =
(not to exceed grand total of $10,500)

Payment Method

How will you be paying your membership dues?
Make checks payable to Missouri Assisted Living Association and mail to:
2407 B Hyde Park Road
Jefferson City, MO 65109

$

I understand a 2.9% plus 30¢ convenience fee will be applied to all credit card transactions.

$
Payment
Name on Card
Name on Card
First Name
Last Name
Billing Address
Billing Address
City
State/Province
Zip/Postal

MALA by-law change effective May 1, 2012. All facilities enjoined by common ownershop/identity of interest of a member facility must also be members. Active members may consist of any facility or other legal entity which is specifically licensed to do business as an ALF or RCF in the State of Missouri.