2010 General Membership Renewal by bvXADQR3

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									                                                                          2012 General Membership
                                                                          Application
                                                                                           Annual Membership Fee $750.00
                                                                            General Members are eligible to vote and hold office.

                                                               Applicant Information
Agency
Name                                                                                                               LHIN
Applicant’s
Name               Last:                                                             First:

Title                                                                                  Years in current position
Do you report directly to the Board of Directors of this organization?                                                         Yes         No
                   Street Address                                                                                         Suite / Unit #
Mailing
Address            City                                                                                                   Postal Code

                                                                                     Phone
E-mail
                                                                                     Fax

                                                           Description of Organization
Website Address
Mission Statement



Services Offered




                                    Less than $1,000,000                                      Between $5,000,000 and 10,000,000
Last Year’s
Total Annual Revenue                Between $1,000,000 and 3,000,000                          Greater than $10,000,000
                                    Between $3,000,000 and 5,000,000

Last Year’s                   Local Health Integration Network                       $
Major Funding                 MCSS                                                   $
Sources
Report Amounts in             Housing                                                $
nearest thousand:             Other, specify if significant:                         $

Number of Clients served last year                                                     Number of Full-time
                                                                                       Employees last year

                                                                   Signature

                           If approved for membership you must agree to abide by the OAILSP Code of Ethics
                                           and Confidentiality Agreement which will be provided.

        As a General Member you will be asked to provide proof of Accreditation by a recognized Accreditation Agency,
                                    or to complete the OAILSP Quality Certification Standards Survey.

Signature                                                                           Date
                                                Please return completed form to:
                                                             OAILSP
                                                       c/o Eleanor LeBlanc
                                                 Email – eleblanc@ableliving.org
                                                      Fax – 905-333-8711
                                        Mail – 1022 Waterdown Road, Burlington L7T 1N3

								
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