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Assisted Living Residencies Application Package
The Assisted Living Residence (ALR) Program application must be completed and contain all documents listed below. The ALR staff reviews all documents and forms and determine if the requirements are met for survey and ultimately licensure. Please follow the instructions for each and include all forms in the application in hard copy format.
- Printable Forms: Print the form, fill it out, sign it, and include it with the application package.
Specific instructions are provided within each form below.
Application Package Documents
- Assisted Living Residence Application [PDF]
- Health Certificate for Staff [PDF]
- Insurance Verification Request Form [PDF]
- Program Statement [PDF]
- Proof of Solvency [PDF]
- Disclosure of Ownership and Interest Statement [PDF]
- Admission Annual Medical Certification [PDF]
- Certification--Clean Hands Act [PDF]
- Voluntary Transfer Discharge and Relocation Document [PDF]