Membership Application | MACSP - Maine Association for Community Service Providers

Membership Application

Agency Name:*
Member Representative:*
Title:*
Address*
Street Address Address Line 2 City State ZIP Code
Telephone:*
Fax Number:*
Email:*
Website:*
Corporate Status:*
- For Profit - Corporation
- For Profit - Individual
- For Profit - Partnership
- Non Profit - Corporation
- Non Profit - Other
Complete the following information for the person who will vote on behalf of the agency when the identified member representative is unavailable.
Contact Person:*
Title:*
Address:*
Street Address Address Line 2 City State ZIP Code
Telephone:*
Fax Number:*
Email:*
Website:*
Year of Incorporation:*
Date started doing business in Maine:*
Date Format: MM slash DD slash YYYY
Has anyone in the management of this organization been involved in a license revocation or forced to close any other organization delivering similar services?*
- Yes
- No
If yes, please describe:*
What is the total revenue that serves people with intellectual and developmental disabilities in the State of Maine?*
(See Dues Categories for additional info on calculating revenue for purposes of membership dues.)
Please list reason(s) for wanting to join MACSP.*
Please complete all applicable information requested. If you are applying for an Associate Membership, please indicate if you have any experience or interest in the following service demographic information.
Agency Name:
Name of member representative:*
Email of member representative:*
Name and email of any staff who should have direct access to MACSP information, including MACSP emails:*
Counties your agency provides services in:*
Please indicate which MaineCare reimbursed services your agency provides access to:
Covered Services under Section #13:*
(ex: agency home supports, community supports, etc.)
Number of individuals served under Section #13:*
Number of employees performing covered services under Section #13:*
Covered Services under Section #19:*
(ex: agency home supports, community supports, etc.)
Number of individuals served under Section #19:*
Number of employees performing covered services under Section #19:*
Covered Services under Section #20:*
(ex: agency home supports, community supports, etc.)
Number of individuals served under Section #20:*
Number of employees performing covered services under Section #20:*
Covered Services under Section #21:*
(ex: agency home supports, community supports, etc.)
Number of individuals served under Section #21:*
Number of employees performing covered services under Section #21:*
Covered Services under Section #28:*
(ex: agency home supports, community supports, etc.)
Number of individuals served under Section #28:*
Number of employees performing covered services under Section #28:*
Covered Services under Section #29:*
(ex: agency home supports, community supports, etc.)
Number of individuals served under Section #29:*
Number of employees performing covered services under Section #29:*
Covered Services under Section #50:*
(ex: agency home supports, community supports, etc.)
Number of individuals served under Section #50:*
Number of employees performing covered services under Section #50:*
Covered Services under Section #65:*
(ex: agency home supports, community supports, etc.)
Number of individuals served under Section #65:*
Number of employees performing covered services under Section #65:*
Covered Services under Section #97 - Appendix F:*
(ex: agency home supports, community supports, etc.)
Number of individuals served under Section #97 - Appendix F:*
Number of employees performing covered services under Section #97 - Appendix F:*
Other IDD Services:*
(ex: agency home supports, community supports, etc.)
Number of individuals served under other IDD services:*
Number of employees performing covered services under other IDD services:*
Please enclose with your application any brochures or other descriptive material you may have related to your facility and its program.
Approval of this application will be based in part upon the information supplied herein. Falsification or misrepresentation of any information considered part of this application would result in disqualification for membership in the Maine Association of Community Service Providers.
CERTIFICATION:*
I certify that the information provided in this application is accurate and complete to the best of my knowledge. The undersigned if admitted to active membership in MACSP, hereby agrees that it will in all respects conform to and abide by MACSP's Pledge, the Bylaws of MACSP, and all amendments hereafter made thereto.
Date:*
Date Format: MM slash DD slash YYYY
Title:*
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Laura Cordes, Executive Director
PO Box 149
Hallowell, ME 04336
(207) 623-5005
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