Membership Application I. Organizational Information Company Name / DBA Legal Entity Name Owners of Record Select Type of Organization Corporation Partnership Limited Liability (LLC) Non-Profit Corporation Nonprofit (other) Unincorporated Entity Other (specify) Specify Organziational Type Year Founded Company Billing Address Street City State Zip Company Mailing Address Street City State Zip Phone Website Principal contact person Name Title Phone Number Email Address Will your organization attend the training workshops within 90 days of certification? Yes No Does applicant own or operate a licensed or certified addiction or mental health program or facility? Yes No Specify Do any of the owners identified in this application have an ownership interest in or any sort of business relationship with a licensed, independent use, confirmatory lab? Yes No If owners have any ownership in any other businesses in the recovery industry please disclose here: Do you operate other types of housing? Yes No Specify type and facility Describe your business Please fill out all fields to proceed II Management and Staff Information All owners, managers and staff are required to register with the credentialing entity (AzRHA). If the legal entity is a corporation with a large Board of Directors or is publically traded as is owned by a broad body shareholders, then the CEO and CFO may register as "Owners of Record". For each contact entered, a unique email address is required and a contact phone number that will be directly answered by that contact. Main switchboard phone numbers and general inbox addresses are not permissible in the contact section of this application. Failure to list all owners, managers, and staff constitutes a fraudulent application that may result in denial and/or revocation of your certificate of compliance. Name Title Direct Phone Direct Email Special Training/Licensure Please Select Role Has Ownership Is authorized to make changes to AzRHA website residence listing Handles intake/admissions In charge of/ involved with marketing House manager Certified Recovery Residence Administrator (FARR) In charge of compliance III Standards, Code of Ethics, Dispute Resolution Do you maintain formal standards for the operation of your recovery residences? Yes No Do you maintain a code of ethics to which all members subscribe, or do your standards contain provisions equivalent to a code of ethics? Yes No Do you agree to adopt the AzRHA Standard for Recovery Residences for all recovery residences operated by your organization? Yes No Do you have a defined process for resolving complaints from residents and the public? Yes No Do you maintain and follow procedures for logging and retaining records of complaints about your residences, and the manner in which they were resolved? Yes No IV Support for AzRHA Mission Are you willing to fully participate in AzRHA organizational activities? Yes No Are you willing and able to support AzRHA-sponsored research initiatives? Yes No Are you willing and able to contribute financially to the operation of NARR by payment of applicable annual affiliate fees? Yes No Do you intend to conform to affiliate requirements which are enacted by AzRHA for adoption by its affiliates? Yes No Do you agree to cooperate with PARR in efforts to resolve complaints received by PARR about the affiliate or about its individual members? Yes No Have you read and do you understand the residence certification requirements? Yes No Have you reviewed the health, safety and management requirements? Yes No Have you read, and do you agree to abide by the Code of Ethics? Yes No Have all responsible persons (see note) read, and signed, the Code of Ethics? Note: A 'responsible person' is anyone in a position of authority or responsibility within the residence, including managers, house captains, senior residents, peer leaders and heads of household. Yes No V Residences General Information Residence Name County Address Please select Type of Ownership Owned by member Leased from 3rd party Leased from self, person or entity related to owner Please select Level of support I II III IV Manager Name Housing Capacity Information Type of structure Single Family Multi Family Apartments Condo Number of Units Number of Bedrooms Number of Beds Number of Bathrooms Other space available? Yes No Pool available? Yes No Gender of Priority Population Men Women LGBT Veterans Pregnant Women Coed Men with Children Women with Children Other Do you welcome Medically Assisted Treatment in your residences? Yes No Is your residence abstinence based? Yes No Recovery Path 12 Step Faith Based Celebrate Recovery SMART Is food included in the fees? Yes No Do you manage resident funds? Yes No Costs Administrative Fee Deposit Amount First and Last Amount Pro-rated Amount Billing Frequency Shared Room Amount Private Room Amount Describe this residence Residence Pictures Thank you for your application - we will get in touch soon!