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 (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 #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 provide the following documents with application: Proof of Liability insurance Business License and/or registration with State of Oregon Proof of 10 Continuing education hours in the past 12 months Drop files here or Select files Max. file size: 32 MB, Max. files: 6. 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 $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.