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Change of Ownership

Change of Ownership

Please provide the following information so that WHCA can update its database, accounting files, and communications information to ensure continued service and support.

Current Facility Name:(Required)

Current Owner:(Required)

New Facility Name:(Required)

New Owner/Management Company:(Required)

New Owner/Management Company Address:(Required)

Street Address Address Line 2 City State ZIP Code

Owner/Management Company Contact Person:(Required)

First Last

Title:(Required)

Email:(Required)

Phone:(Required)

Address (if different than above):

Street Address Address Line 2 City State ZIP Code

Website URL for Facility:

Billing/Invoice Contact Person:(Required)

First Last

Title:(Required)

Email:(Required)

Phone:(Required)

Address (if different than above):

Street Address Address Line 2 City State ZIP Code

Effective Date of this Change in Ownership:(Required)

Facility Administrator/Executive Director Contact:(Required)

First Last

Title:(Required)

Email:(Required)

Phone:(Required)

Facility DNS/Health Services Director Contact:(Required)

First Last

Title:(Required)

Email:(Required)

Phone:(Required)

Person Completing This Form Contact:(Required)

First Last

Title:(Required)

Email:(Required)

Phone:(Required)