OSRAA Membership Application OSRAA Agency Membership Application Applicant InformatoinApplicant Name First Last PhoneEmail Business InformationBusiness Name Address PhoneEmail Number of Employees Doing PlacementYears in Placement BusinessOther company affiliated businesses Additional Placement Staff, Titles & Emails 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/ Intermediate care facility Other Affiliations (Please list any memberships in age related associations such as OGA, Elders in Action, MSN etc.) Why do you want to be a member of OSRAA?ReferencesList 3 Professional References. At least one must be an assisted living community, memory care community or adult care home; and one must be a client. Please advise your references that one of OSRAA’s board members will contact them.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 #3Qualifying InformationDo you preview care homes prior to referring clients? Yes No Do you meet with client/family in person? Yes No Do you tour with your clients? Yes No Are you affiliated with/owner of a senior housing company, community, ACH? Yes No File UploadPlease upload these documents: Certificate of Insurance (COI). General and Professional Liability in the amount of $1MM are required. Registration Certificate from Oregon DHS Drop files here or Select files Max. file size: 32 MB, Max. files: 6. Authorization(Required) I authorize OSRAA to verify the information provided on this form, and to further solicit additional industry references as OSRAA deems desirable. I have read OSRAA’s Code of Ethics and By-Laws, and agree to abide by them. Additionally, all my current and future employees and affiliated independent contractors who are involved in placement have/will read them, and agree to abide by them. Notes: Yearly membership dues are $450 for agencies operating in Portland Metro Area, and $300 for agencies operating outside the Portland Metro Area. Please allow 4-6 weeks for process of application, upon approval, annual dues will be assessed.