Exploring PACE Membership

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Exploring PACE Membership Application

Please note that required questions are marked with an *

Your Individual Contact Information

Full Name, including Postnominals (like RN, MD, MPA, etc.)*

Job Title*

Email Address*

Preferred Phone Number (Direct Line/Extension/Mobile Phone)*

Member Organization Profile Information

Preferred Organization Name*

The preferred name that the organization uses to market itself to the general public.

Legal Organization Name (if different)

EIN

Full Mailing Address of Organization (including city, state and zip)*

Main Phone Number*

This is generally a main administrative office phone number.

Website or Webpage for Organization*

How did you hear about NPA?

Additional Colleagues for Membership Benefits

You may have other staff at your organization who are involved in the PACE exploration process and would benefit from NPA member benefits. Our memberships are done on an organizational basis. Once your organization is approved as a member, all of the benefits of membership are available to anyone on your team.

Do you have other staff that you would like to have added?*

Yes, and I will upload a staff list below

Yes, but reach back out to me in a bit for it

Yes, but I'll have them create their own (you'll tell me how after our membership is approved)

No, I'm the only one for now (but I may add others later on)

Other...

Other Staff Contacts

If you are creating a list, we'll need the same information that we asked for you above (full name, postnominal, job title, email, preferred direct phone number). Or, if it's easier for you, feel free to upload an existing staff roster. Word and excel files preferred, but we can also accept PDF files.

Current State of PACE Development

This information is optional, but helps us to better serve you and your organization's particular needs.

How would you describe where you are in the PACE decision making process (e.g. whether or not to commit to starting a PACE program)?

At this time, are you partnering with any other organizations in your PACE exploration, as a potential joint venture? if so, please describe.

At the end of your Exploring PACE membership year, what would you have gained from the membership that would cause you to look back and consider it a good return on your investment?

Ready to Submit?

I accept NPA's member code of conduct.*

Yes

I accept NPA's antitrust policy and guidelines.*

Yes

Review Code of Conduct and Antitrust

Your membership application must first be approved, and then you will be invoiced. Membership in NPA will not begin until payment in full is received. Membership is non-refundable. Please signal your acceptance by checking "yes" below.*

Yes

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Exploring PACE Membership