LOS ANGELES COUNTY SOBER LIVING COALITION Part of the Sober Living Network, a 501(c)(3) nonprofit corporation

Field Office: 2531 E. James Ave, West Covina, CA 91791 (626) 712-1348 Fax (626) 915-4426 E-mail: slnetwork@earthlink.net Web Site: www.soberhousing.net

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MEMBERSHIP APPLICATION Membership and 1st residence ($395) Current Member New Member Additional residence ($240) Current Member New Member

(Fees include a $35 per house non-refundable inspection fee. See Appendix 1.)

Date_____/_____/ Member ID: __________ (leave blank if none) Residence ID: __________ (blank if none)

Section I: Residence Information (please submit one application per residence)

Residence name: ________________________________________________

Residence address:

City: ________________________________________________ State: ___ ZIP:________

Mailing address: ______________________________________ City: _________________________ Zip:___________

Website address (if different from member web address): ___________________________________________

Residence is owned by member leased from third party leased from person or entity related to member

Date residence established ____________

Type of structure: single family detached house Apartment building One or more apartment units

Condominium unit(s) Duplex or triplex Other:

Number of bedrooms: _____ Number of bathrooms: ____ Other available space:

Resident capacity:_____ Serving: Men Women Women with Children Co-ed Men with Children

Other population (list here): ___________________________

Level of resident support (1-4, see Network description of Levels of Support): ___

Resident fees: Basic monthly $______________ More than one fee for accommodations in this residence? yes no

Is food included as part of resident fees? yes no

Section II: Member Information (information on the organization or individual operating this residence) Member/applicant name: _____________________________________________

Type of organization: __ corporation ___ partnership ___ limited liability company (LLC) ___ sole proprietorship

__ nonprofit corporation __ nonprofit-other __ unincorporated entity __ other

Member/applicant business address: ________________________________________________________

City: ____________________ State: ____ ZIP: _____________

Website address: ___________________________________

Does applicant own or operate a licensed alcohol & drug or mental health program or facility? __ yes __ no

If yes, name of licensed program(s) or facility(ies): ___________________________________________________________

Number of recovery residences operated by this organization: _____

Membership application Los Angeles County Sober Living Coalition

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Are you willing to fully participate in Coalition and Chapter activities? YES NO

Have you read and do you understand the Coalition membership 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

Section III: Contact Information (member, residence, Network website): For help in completing this section please see Appendix 3 below. Principal business contact for this member organization: Name: ___________________________________ Position title or duties: __________________________________

Principal contact phone: ( ) _______-______________ Principal contact email: _______________________________

Responsible person for this residence (Manager, senior resident, peer leader, house captain or equivalent): Name: ____________________________ Position title or duties: _________________________________________

Responsible person phone: ( ) _______-__________ Responsible person email: ________________________________

Residence contact information to appear on the Sober Living Network website: Website contact name ____________________________

Website contact phone: ( ) _______-____________ Website contact email __________________________________

Section IV: Training (member and home) Has someone active in the management of recovery residences for this organization completed the Developing & Operating Quality Sober Living Homes workshop? yes no

If yes, person completing workshop: _________________________________

Job title, organizational role or duties: ________________________________________________________

Date training completed: ____/___/____

Has someone active in the operation or peer support for this residence completed the Leadership Training workshop?

yes no

If yes, person completing workshop: _________________________________

Job title, organizational role or duties: ________________________________________________________

Date training completed: ____/___/____

Section V: Applicant affidavit and signature I hereby attest that the above information is true and complete, and that I am authorized to execute this application on behalf of the applicant. Applicant hereby requests membership in the Los Angeles County Sober Living Coalition.

___________________________________________ ______________ (Signature) legal representative of applicant Date

___________________________________________ Name (please type or print)

Membership application Los Angeles County Sober Living Coalition

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Appendix 1: Explanation of Fees and Charges (effective May 1, 2014) The Los Angeles County Coalition membership fee has two componentsan annual fixed amount (currently $155) and a per-residence fee of $240. That means the first home fee (including your membership fee and the per-home fee for one home) for on-time renewals is $395. The fee for each additional home is $240.

Membership and Inspection Fees

Membership fee 155.00

Per-residence fee (annual per residence) 240.00

One inspection per home per year Included

Additional inspections $35

Fees due upon application are as follows: Membership plus first residence fees: $155 member fee + $240 per-residence fee. Total $395.00

Each additional residence: payable for additional new or renewal residences. $240 per additional residence

Additional charges:

All onsite work to certify or re-certify a home is designed to be completed in one inspection visit. If more than one visit is necessary in order to complete an inspection, to collect payments or if the residence must be re-inspected due to identified deficiencies or as the result of a verified complaint, an additional $35 per visit will be charged, payable before the visit can be scheduled.

Membership Assessments The housing rights fund is earmarked specifically for activities necessary to protect the fair housing rights of our residents and homes. In past years the Coalition assessed members $100 annually per home for this activity. The Coalition did not levy an assessment in 2012 or 2013.

Beginning in May 2014 the housing rights fund is being reinstated, and your contribution is included in your member fees.

Membership application Los Angeles County Sober Living Coalition

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This Page for Coalition and Network Use Only Member ID: ____________ Residence ID: _____________

Inspection assigned to _________________________________ Date: ________________

Inspection completed by _______________________________ Date: ________________

Documents reviewed by _______________________________ Date: ________________

MEMBERSHIP REQUIREMENTS CHECKLIST Membership application complete, OK? Membership Fee Fully Paid? Completed two training workshops? Signed the Code of Ethics? General Liability Insurance and Endorsement? Website, Residence Brochure, Info Sheets? Resident Agreements? House rules, other resident documents OK? Residence application? Rules, Regulations and/or Policies for residence staff and peer leaders? Current and past assessments fully paid? Level of resident support (1-4, see Network description of Levels of Support):

Discrepancies Noted: Yes No Date QA site review sent to applicant: ___/___/_____ This recovery residence meets all the coalition membership requirements and is approved for membership.

Approved By: ___________________________________________________________ ___/__/_____ Los Angeles County Coalition Field Office Date

Send copy of application to Network Offices for certificate preparation and referral listing.

Approved by: ________________________________ ___/__/_____ Sober Living Network Office Date

Certificate prepared and delivered. Date: ____________ By: ______________________________

Additional notes and comments

MEMBERSHIP APPLICATIONWebsite address (if different from member web address): ___________________________________________Residence is owned by member leased from third party leased from person or entity related to memberWebsite address: ___________________________________

Principal business contact for this member organization:Responsible person for this residence (Manager, senior resident, peer leader, house captain or equivalent):Name: ____________________________ Position title or duties: _________________________________________Residence contact information to appear on the Sober Living Network website:Website contact name ____________________________Website contact phone: ( ) _______-____________ Website contact email __________________________________

MEMBERSHIP REQUIREMENTS CHECKLIST Membership application complete, OK?Discrepancies Noted: Yes No Date QA site review sent to applicant: ___/___/_____