Check List To Help Customize Your Material/Application:

1. Organization's Name:

2. Organization's Address:

3. Organization's Website:

4. Organization's Ownership (Name of Individual(s) who directly owns the home care organization:

5. Address of ownership if Different from Organization's Address:

6. Telephone Number of Ownership if Different from Business Telephone Number:

7. Organization's Federal Employer ID Number:

8. Organization's County:

9. Organization’s Geographic Service Area (Counties you are interested in doing business e.g Prince William County, Fairfax County, Arlington County, Loudoun County, Warren County etc.):

10. Organization's Branch Offices (eg: will organization operate one or more branch offices ?

Yes

11. Organization’s Drop Site if any (a drop site is a location that the organization uses to obtain office supplies, using fax and copy machines) – will the organization operate a drop site?

Yes

12. Names of Administrative Personnel and their job Titles (e.g Administrator etc...):

13. Certifications of Administrative Personnel (do they have Virginia licenses?)

Yes

14. Estimated Number of Direct Hires (e.g CNAs, home attendants, licensed nurses etc…):

15. Estimated Number of Contract Employees (e.g CNAs, home attendants, licensed nurses etc…)

16. Organization's Phone Number:

17. Organization's Fax Number if any:

18. Organization's Office Hours:

19. Organization’s Days of Operation: M-F?

20. Organization's Email Address:

21. Organization’s Logo – this may be emailed

22. Organization’s Slogan if any:

23. Names of Organization’s Governing Body (e.g Nursing Director – must be an RN, Financial Manager and Administrator):

24. Name of Alternate Administrator:

25. Organization’s Formation (e.g LLC, Corp, Partnership etc.):

26. Services Provided (e.g skilled nursing service, personal care services, pharmaceutical services, respiratory therapy, physical therapy, occupational therapy, speech therapy and other):

27. Organization’s Mission Statement:

28. Organization’s Philosophy:

29. Organization’s Vision:

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