BECOME A PARTNER BECOME A PARTNER Partnership Application Type of BusinessDate* Date Format: MM slash DD slash YYYY Contact Person's Information:Name* First Last Phone*Email* Company Information:Company Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country WebsitePhone*Website Placement:To be included on the Life Options Pittsburgh Website for your Services and Products, please select up to 3 Business Categories; and provide your company tagline, and profile choice:Categories* Accessibility Assessments, Expert Witness Accessible Modifications for Home & Business Adult Day Center Anti-aging — Body Skin Care Anti-aging —Brain Anti-aging — Face and Eyes Assistive Technology Audiology (Hearing) Banking Services Captioned Telephones Caregiver Support Cemetery Green Burial Commercial Real Estate Services Daily Money Management Dementia Care Diabetic Footware and Custom Orthotics Downsizing Durable Medical Equipment Elder Law Estate Planning Final Expense & Life Insurance Financial Planning Financial Services Fitness Classes Fitness Facility Funeral Planning Services Geriatric Behavioral Health Care Geriatric Care Management Geriatric Counseling Genetic Testing Genetic Screening Guardianship Power of Attorney Health and Wellness Screenings Hearing Aids Hearing Testing / Screening Home Health Care — Medical Home Health Care — Non-Medical Home Medical Equipment - Care Home Medical Equipment - Medical Hospice and Palliative Care Identity Theft Independent Living Facility Insurance Plans and Products Investment Advising Legal Services Long-term Care Education & Planning Media Marketing Medical Staffing Medical Supplies and Products Medicare Plans Mental Health Nursing Home or Skilled Nursing Care Facility Personal Care Communities Personal Emergency Response Equipment Pharmacy Physical Therapy Print and Digital Marketing Professional Organizing Radio Marketing Real Estate Services Rehabilitation Respite Services Security - Caregiver Support Security Camera Services Senior Advocacy Senior Counseling Senior Fitness Senior Moving Services Senior Online Marketing Services Service Coordination Social Security Planning Special Needs Trust Management Stairlifts, Ramps and Wheelchair Lifts Sustainable Living Transportation Veteran’s and Medicaid Planning Veterans Benefits and Assistance Waiver Services Your Company Tagline*Profile Choice*Use information from websiteUse custom profile (below)What LOP committees or activities would you like to serve on? Events & Social Gatherings Marketing, PR & Social Media Website Sub-Committee Membership (Use for Custom Profile)How did you hear about LOP?Please be noted that when you click on the submit button of this form, you will be redirected to our checkout page where you will be able to make the subscription payment.Payment Options*Cash/CheckCredit CardMembership Payment (Cash/Check)*New Active Partner Membership (effective January to June) $60.00New Active Partner Membership (effective July to December) $30.00Membership Payment (Credit Card)*New Active Partner Membership (effective January to June) $60.00New Active Partner Membership (effective July to December) $30.00Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name CAPTCHANameThis field is for validation purposes and should be left unchanged. 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