OSRAA Business Partner Application OSRAA Business Partner Membership Application Applicant InformatoinApplicant Name First Last PhoneEmail Business InformationBusiness Name Address PhoneEmail EINNumber of EmployeesYears in Placement BusinessPlacements are ____ % of your annual business:Other company affiliated businesses Additional Placement Staff, Titles & EmailsAffiliations (Please list any memberships in age related associations such as OGA, Elders in Action, MSN, OHCA, etc.) ReferencesList 3 Professional References (include at least one Assisted or Memory care community and/or Adult Care Home and one client with whom you’ve worked). **OSRAA will independently solicit industry references in addition to the contacts supplied here. Name - Contact #1 Company - Contact #1 Email - Contact #1 Phone - Contact #1Name - Contact #2 Company - Contact #2 Email - Contact #2 Phone - Contact #2Name - Contact #3 Company - Contact #3 Email - Contact #3 Phone - Contact #3Additional InformationWhen doing placements, do you preview care homes prior to referring clients? Yes No What is your process when working with placement clients?Do you provide personalized assessments and tour with your clients? Yes No Do you tour with your clients? Yes No If noIf no, please describe how your referral agency worksDo you check county Public Disclosure Files for adult care homes and assisted living communities (including memory care) complaints?Check Oregon.gov On line Database Yes No check filesCheck files in county licensor office Yes No If yesIf you selected yes for either response, please describe process and frequencyDo you have current liability insurance? Yes No If you have a staff, do you have written policies and procedures? Yes No Are you affiliated with a senior housing company, community or personally own more than a 2% interest in an Adult Care Home, Community or Home Care Company? Yes No To what types of places do you refer (please check all that apply)? Independent Communities Assisted Living Memory Care Adult Care Homes CCRC Retirement Communities Skilled Nursing Have you ever been arrested or convicted of any misdemeanor felonies? Yes No If yesIf yes, please explainAre you willing to submit to a criminal background check as a part of this application? Yes No Do you require your staff to pass criminal background checks? Yes No Do you pursue continuing education in the field of senior housing and care? Yes No Why do you want to be a member of OSRAA?Authorization(Required) I authorize the verification of the information provided on this form as to my involvement in membership in Oregon Senior Referral Agency Association. I have received a copy of this application I have read the Code of Ethics for the Oregon Senior Referral Agency Association and if a member of the organization, hereby agree to abide by its terms. Notes: Yearly membership dues are $300 for Business Partners. Please allow 4-6 weeks for process of application, upon approval, annual dues will be assessed. Δ