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Membership Application

 

The Maryland Association of Community Services (MACS)

for Persons with Developmental Disabilities, Inc.

10632 Little Patuxent Parkway, Suite 254 # Columbia MD 21044

410-740-5125 (Baltimore/Annapolis); 888-838-6227 (DC Metro); 410-740-5124 fax

http://www.macsonline.org               Email: macs@macsonline.org

 

FY 2010 Agency Membership Application

Please print all information as you wish it to appear in our membership directory.

 

AGENCY NAME:______________________________________________________________________

 

Executive Director:_____________________________________________________________________

 

Proxy: ______________________________________________________________________________

 

ADDRESS:___________________________________________________________________________

Mailing Address & Suite Number or PO Box

 

____________________________________________________________________________________

City                                                                                                   State                                                        Zip

 

TELEPHONE _______________________________  FAX____________________________________

 

EMAIL: _______________________________ Website: ______________________________________

 

Geographic region agency serves:  _______________________________________________________

 

 

Types of supports agency provides

 

# served

 

Adults

 

Children

 

Group Homes (4 or more)

 

 

 

 

 

 

 

ALUs (3 or fewer)

 

 

 

 

 

 

 

CSLA

 

 

 

 

 

 

 

Supported  Employment

 

 

 

 

 

 

 

Day Habilitation

 

 

 

 

 

 

 

Medical Day Care

 

 

 

 

 

 

 

Resource Coordination

 

 

 

 

 

Agency funding sources:  ______________________________________________________________

 

Locations of other offices: (use back if necessary)    _______________________________________________

 

Number of years agency has been operating:  ______________________________________________

 

Number of full time staff: ______________________    Number of part time staff: __________________

 

 

  

 

MACS has several e-list-servs for information exchange with various committees. The information you provide below will help MACS to better inform our members about important issues. 

 

Most information is emailed.  Please indicate the appropriate person if someone other than the executive director is to receive info concerning the following:

 

 

Position

 

Name

 

e-mail

 

Public Policy

 

 

 

 

 

Quality Assurance

 

 

 

 

 

Training

 

 

 

 

 

Nursing

 

 

 

 

 

Res/CSLA

 

 

 

 

 

Sup. Emp

 

 

 

 

 

Day Habil.

 

 

 

 

 

Medical Day

 

 

 

 

 

F/ISS

 

 

 

 

Resource Coordination

 

 

 

 

Children

 

 

 

 

 

CFO

 

 

 

 

 

HR

 

 

 

 

 

Please return this form via mail or fax to the MACS office along with your dues application or renewal.



 

THE MARYLAND ASSOCIATION OF COMMUNITY SERVICES (MACS)

For Persons with Developmental Disabilities, Inc.

10632 Little Patuxent Parkway, Suite 254  Columbia, MD  21044

Tel:  410-740-5125   Fax: 410-740-5124

Federal id # 52-1664511

 

 

Invoice

 

 

AGENCY NAME:                                                                                                                                               

FY09 Agency Dues   7/1/09 – 6/30/10

 

 

Agency dues will be calculated based on total operating budget.

 

 

1) Multiply the first $3 million of that total by .0012 = $ ___________________

 

2) Multiply the balance by .001 =                                    $ ___________________

 

TOTAL – add 2 lines together for total dues** =         $ ___________________

 

 

** Note:  If amount is less than or equal to $500 dues are $500. If amount is greater than $7100, then dues are $7100.

 

 

Payment is due upon receipt.  Please include this invoice with your payment.  Thank you.