Assisted Living Registry - Your directory for Assisted Living, Independent Living, Hospice and Alzheimer Facilities across the nation.

assisted living site submission form

Assisted Living Registry Site Submission Form.

Using our secure order form, submit your site for listing on our Assisted Living Registry. Select either non-sponsered, sponsered or premium listings (see examples below). Select the catigories you wish to be listed in and enter your contact and site information. If selecting a sponsered or premium listing, please include your credit card information. This is a secure form so your information will be protected.

Contact Information:

Customer Name

Street number

City State Zip code

Phone Number Fax Number

E-Mail

Billing Information (for sponsered and premium listings)

Same as contact info

Customer Name

Street number

City State Zip code

Phone Number Fax Number

E-Mail

Credit card Info:

Name on Card

Credit Card Type Credit Card Number

Exp. Date Security Code

Note: An e-mail verification letter will be sent to confirm your order.

Non Sponsored (Free) Listing Information:

Site Name Website Address

Catigory Sections

Assisted Living Hospice Care Alzheimer Care

Description (up to 140 char.)

Sponsored and Premium (Paid) Listing Information:

Site Name Website Address

Picture (160x150 Pixels)

Catigory Sections

Assisted Living Hospice Care Alzheimer Care

Description (up to 550 char.)

Note: Premium listing will contain information above on a seperate

page per location. An E-Mail confirmation will be sent to confrim order.

By clicking submit I agree to the terms listed below.

I authorize Cimino Computer Consulting to charge my credit/debit card for this one-time payment of my bill as indicated above. In the event Cimino Computer Consulting is unable to secure funds from my credit/debit card for this transaction for any reason, including but not limited to, insufficient funds in my credit/debit card account or insufficient or inaccurate information provided by me when I submit my electronic payment, further collection action may be undertaken by Cimino Computer Consulting including application of fees to the extent permitted by law.