Application for Membership Step 1 of 5 20% I. Apply for MembershipThank you for considering membership to the Bucks County Long Term Care Consortium. The membership fee is $100.00. Membership fees are due annually and can be paid via mail or by PayPal. Per our bylaws, Consortium Members shall be a licensed organization or facility providing care or health related services to the long term care population in Bucks County. Members shall be entitled to one vote in any election or business at the general meetings. Please note that organizations with multiple sites must apply for membership for each location. Your website will be linked to our member organization page. Again, thank you for your interest. Please feel free to contact us if you have any questions regarding membership dues, benefits, committees, and more. It is our expectation that you, your employees, and the clients/residents you serve will benefit greatly from your involvement with the Bucks County Long Term Care Consortium. For details about membership, please review the current Consortium Bylaws (PDF document).Membership Option*Consortium MembershipClick to continue II. Facility/Organization InformationPlease tell us more about your organization.Organization Name*Organization Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*BucksBerksChesterDelawareLehighMontgomeryNorthamptonPhiladelphiaNJ - MercerNJ - BurlingtonNJ - CamdenNJ - GloucesterNJ - WarrenState of DelawareOtherPhone*FaxOrganization Website* Please enter the full web address. A link to your organization's website will be included in the Member Directory.Organization Type* SNF Assisted Living Independent Hospital Other Select all that apply. III. Primary Contact for OrganizationPlease provide information for your primary contact.Contact Name* First Last Title/Position*Email* Primary contact's emailSecondary Email If desired, please enter a secondary email address (recommended). IV. Additional Contacts(Optional) Enter additional contact information here.Contact #2 Name First Last Contact #2 TitleContact #2 Email Contact #3 Name First Last Contact #3 TitleContact #3 Email Contact #4 Name First Last Contact #4 TitleContact #4 Email V. Select Dues Payment Option And Submit Your ApplicationPlease check the following to agree to the terms of the Bucks County Long Term Care Consortium's Bylaws (Adobe PDF) and complete your application. Once completed, you will receive an email confirmation of your enrollment with an invoice. If paying by check, please forward to: The Bucks County Long Term Care Consortium P.O. Box 2001 Warminster, PA. 18974 If paying online, you will be directed to our online payment page after your submit this form.Annual Dues*Please enter a number from 100 to 100.Payment Option*Pay by CheckPay Online (PayPal)NOTE: A PayPal account is NOT required to pay online with a credit card.Agreement*I agreeI declinePlease indicate your intention to become a Consortium Member Facility.Validation