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We will need the following information filled out so that we can begin processing your company profile page on 

Please review our Merchant Terms and Conditions prior to submitting your company.  If you will be supplying us with an image, please review the image requirements page.

Any N/A answer will not be referenced in your profile page.  If a field does not apply to your company, complete that field by choosing the N/A option or typing N/A into the appropriate field.

Please provide the following information about your company.  Fields in RED will not be published but are used for SeniorMag management purposes only: 

Company Name
Street Address
Address (cont.)
Your E-mail
Not Published
Contact Email
Website Address

Primary business location: 

Primary business category: 

Secondary business categories under which you would like to be listed:

Suggest a different category:

In-home services available?  Yes  No  N/A

Business hours: 

On call services available?  Yes  No N/A

Are services covered by Medicare?  Yes  No Sometimes  N/A

Emergency contact number (if any): (xxx)xxx-xxxx

Years in business: 

Associations and affiliations:

N/A  BBB  Chamber  Professional

Professional or other organizations of which you or your company are a member:

If your company is an assisted living/real estate oriented company (e.g. retirement center, group home, etc) where there is a monthly charge and you want to list a price range, enter monthly minimum and maximum figures in (U.S.) dollars:

Minimum      Maximum 

Special senior discounts or programs? 

Professional license? 

Professional license number (optional):

Other accreditations: 

Number of employees: 

Does your company maintain workman's compensation?  Yes  No

Other types of insurance that your company has and wants mentioned on your company profile (optional):

Does your company check employee criminal records? 

Are employees bonded? 

Does your location have wheelchair access? 

Does your location have other handicap facilities? 

Are you on a bus line? 

What is your geographical area of coverage?  Hold Ctrl key to select more than one:  Note - this field is primarily for service companies that provide services at a client home.  If you require patrons to visit your location, this field probably does not apply and you should pick the N/A option.


Other service area definition (ex. by zip code): 

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Please input your text that will be used in the body of your page.  Please note that SeniorMag will not edit your text.  It should conform to our merchant rules of conduct.  You are responsible for spell-check, grammar, and punctuation.  No HTML tags are allowed.  SeniorMag reserves the right to format the text according to our site format requirements:

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If you have been given a subscription code (for example at the bottom of an email or advertisement), please insert that code above.  If you do not have an subscription code, then it is not required.

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