First Name
Last Name
Name on License
Phone
Email
State
Zip Code
Number of Licensed Beds
Effective Date Requested
Limit of Liability Requesting
Is there a swimming pool on the premises?
Yes No
Do you accept residents under age 18?
Yes No
Do you have alarms on all exterior doors?
Yes No
Is your facility inspected by the fire department annually?
Yes No
Do you utilize a Negotiated Risk Agreement with residents?
Yes No
Do you record medication and medical records on a computer system?
Yes No
Do bedridden and wheelchair dependent residents exceed 50% of your residents?
Yes No
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