Membership Application Form Name* First Last Business or Organization* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Number*Mobile Number*Email* Website* License or Certification number* Are you insured and bonded?* Yes No Date of Birth* MM slash DD slash YYYY Do you have E & O Insurance?* Yes No Category*Elder LawyerEstate planningEstate Sales specialistFuneral preplanningHome maintenance/remodelingHospice careLong term care insuranceAdult day careLife settlementsSenior movers & Senior move managersHealth & wellness serviceEstate sales specialistsMediation serviceMedicare/Medicaid specialistAssisted Living Facilities/HousesIn home care - MedicalIn home care- Non-medicalIn home care - Skilled nursesCPAFinancial plannerTransportation servicesVeterans benefits specialistMedical alert & home safetyAssisted living locator servicesElder care managementMemory CareIndependent LivingPersonal Care HomeCCRCAssisted LivingOtherDo you use social media?* Yes No If Other selected for Category please list it here. Consent*I, the undersigned, acknowledge and agree to follow all of the rules of The Estate Concierge, and agree to be bound by the policies and procedures contained therein, including permission to use your likeness, company, and photos for social media and marketing purpose. Additionally, I agree to allow the The Senior Estate Concierge to debit my credit card monthly for the amount listed above. I understand the membership can be terminated at anytime with a 60 (sixty) day notice. I also understand I will be debited 2 (two) months after they are notified. I agreeSignature*Printed Signature* Date of Signature* MM slash DD slash YYYY Non-refundable Signup fee Price: Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Δ
