Your Complete Name:

Your Title:

Your Business Name:

Business Address, City, State, Zip:

Mailing Address:

Business Phone:

Mobile/Cell Phone:

Contact e-mail Address:

Business Website Address:

Occupation/Category:
---Accounting ServiceAdult Day CareAssisted LivingAttorneyCarpet CleanersComputer Service & RepairContractor/RemodelerCrime PreventionCustom JewelerDaily Money ManagerDental ServicesDownsizing/DeclutterElder LawElectrical ContractorEstate ServicesFiduciary/Advocate/ GuardianFinancial AdvisorFinancial ServicesFuneral Pre-Planning/TrustGeriatric Care ManagerHandyman ServicesHome Care ServicesHome Health CareHome InspectorHome MaintenanceHome ModificationsHome Safety AdvisorHome SecurityHVAC Installation & RepairInsuranceInterior DesignLandscapingLife Care ConsultantLocksmithMaid/Cleaning ServiceMobility/AccessibilityMoving/StorageNatural Health ProviderOccupational TherapyPest Control ServicePet SittersPhysical TherapyPlumberProduct ManufacturerProfessional OrganizerReal Estate AgentReverse Mortgage ProviderRoofing ContractorSenior Living AdvisorSenior Move ManagerSmart Home TechnologyOTHER

Relationship of Parties:

Age Safe America, LLC ("ASA") and the applicant or ("MEMBER") do not intend by this Agreement to create the relationship of partners, joint ventures, or employer‐ employee. The MEMBER is engaging Age Safe America for the specific purpose of becoming a Member and/or inclusion in the Services Registry and aligning with our mission and vision.

Use of Member Information:

The information gathered throughout the process of the Corporate Membership application is intended for the review of the ASA staff and/or Board of Directors. Certain parts of the application are intended to be shared publicly. Generally speaking, shared information includes marketing-type content such as: company name, provided services, location, and contact data. You hereby grant Age Safe America, LLC ("ASA"), and/or its authorized agents, the rights to use the information herein, as defined above, for informational, publicity, or promotional purposes.

Use of Member Logo:

Age Safe America hereby grants to MEMBER a limited, non-exclusive, non-transferable, revocable right to use the ASA Corporate Member logo and/or Age Safe® America Seal of Approval logo ("Marks") in their marketing and advertising efforts. The logos are the sole property of Age Safe America, LLC (“ASA”) but may be used by ASA Corporate Members in Good Standing in accordance with the terms and conditions set forth below. Use of one or more of the logos shall constitute consideration for, agreement to, and acceptance of the following terms and conditions by the MEMBER:

The attached logos are the sole and exclusive property of ASA. These logos may be used only by ASA Members in Good Standing if and only if such use is made pursuant to the terms and conditions of this limited and revocable license. Any failure by a member to comply with the terms and conditions contained herein may result in the immediate revocation of this license, in addition to any other sanctions imposed by ASA. The interpretation and enforcement (or lack thereof) of these terms and conditions, and compliance therewith, shall be made by ASA in its sole discretion.

The logos may not be revised or altered in any way, and must be displayed in the same form as produced by ASA. The logos are three color. The official colors of the logos are Red, White, Blue and Gray. The logos must be printed in their official colors or in black and white. The logos may be used in a professional manner on the member's business cards, stationery, literature, advertisements, storefront window, Web site, or in any other comparable manner to signify the user's membership in ASA. The logos may never be used independent of the term "MEMBER," as set forth on the Attachment. Notwithstanding the foregoing, the logos may not be used in any manner that, in the sole discretion of ASA: discredits ASA or tarnishes its reputation and goodwill; is false or misleading; violates the rights of others; violates any law, regulation or other public policy; or mischaracterizes the relationship between ASA and the Member, including but not limited to any use of the logos that might be construed as an endorsement, approval (other than the Seal of Approval) , sponsorship, or certification by ASA of the user, the user's business or organization, or the user's products or services, or that might be reasonably construed as support or encouragement to purchase or utilize the user's products or services.

Use of the logos shall create no rights for users in or to the logos or their use beyond the terms and conditions of this limited and revocable license. The logos shall remain at all times the sole and exclusive intellectual property of ASA. ASA shall have the right, from time to time, to request samples of use of the logos from which it may determine compliance with these terms and conditions. Without further notice, ASA reserves the right to prohibit use of the logos if it determines, in its sole discretion, that a Members logo usage, whether willful or negligent, is not in strict accordance with the terms and conditions of this license, otherwise could discredit ASA or tarnish its reputation and goodwill, or the user is not an ASA Member in Good Standing.

Age Safe® America, Age Safe®, Age Safe Check-in™, Age Safe Assessment™, Age Safe Advisor™, Age Safe® APPROVED, Age Safe® America Seal of Approval and Age Safe at Home™ are either USPTO Registered Trademarks, Pending USPTO Registered Trademarks or Trade Names all belonging to Age Safe America, LLC. A MEMBER will not use ASA's trade names or abbreviation in their corporate title and/or business name or in any way that might result in confusion as to separate and distinct identities of Age Safe America, LLC and MEMBER. MEMBER recognizes and acknowledges ASA 's ownership and title to the Marks. MEMBER further agrees not to contest or take any action in opposition to any trademark, service mark, trade name or logo of ASA or to use, employ or attempt to register any mark or trade name which is similar to any mark or trade name of ASA.

Term and Termination:

This Agreement shall be effective as of the date signed and shall remain in full force for one year. On each anniversary of that date thereafter, the Term shall be extended for an additional year, unless it is terminated by action of ASA or the MEMBER. In the event a MEMBER violates any applicable laws, regulations or generally accepted ASA guidelines or engages in conduct that is malicious, deceptive, misleading, fraudulent or illegal, including but not limited to inactivity or breach of any requirements of this Agreement, ASA reserves the right, at its option and sole discretion to terminate this agreement.

Governing Law:

This Membership Agreement shall be governed by the laws of the state of Florida.

Annual Membership Fee:

Corporate Member: $2500.00

Members in Good Standing Agree to:

• Adhere to our Code of Conduct and Fair Practice
• Remain current on their annual membership fees.

Payment of Membership Fee is in no way a guarantee that you will be accepted as a Member. If you are NOT accepted as a Member, the Membership Fee will be refunded in full. Payment of Membership Fee is in no way a guarantee that your product will receive the Age Safe® America Seal of Approval.

Applicant Verification:

I certify that the information provided herein is accurate and complete. I or the business that I represent further agree that all disputes and claims, individual or severable, involving this Membership will be submitted to the Age Safe America Directors for final resolution, and their decision is binding and cannot be appealed. By typing your name below you are signing this document and representing that you have read and understand this Membership Application Agreement.

Full Name Signature: