SeniorMag Merchant Submit Form

Senior Residence Listing

This information will be used to create your company profile page. Please be sure that all information is accurate and provide as much information as you would like prospective clients to see.

Your email address is required but will not be listed under a free listing. If you choose to have your email address and/or web site listed a $50 charge will apply and be billed to the email address listed.

Fields in red are required.

Please provide the following contact information:

Name

Title

Organization

Street Address

Address (cont.)

City

State

Zip/Postal Code

Work Phone

FAX

E-mail

Website URL

Primary type of facility:

Independent living units:
Assisted living units:
Nursing care units:
Alzheimer's/memory units:

Do you wish to have your email address and/or web address listed? A charge of $50 per year will apply and be billed to you electronically through the email address listed above. You may either remit online via credit card (MC or Visa) accepted or via company check.

No
Yes

Have you reviewed and agree to SeniorMag's Terms and Conditions (link opens new window, close to return to this page)?

Yes (An answer of yes is required.)
No

Listing your organization