Consulting

Ph: 702.236.6844 Fax: 702.844.8465

LTCMgtConsultants@gmail.com nvltcmgtandconsult.com
COMPLIANCE
Consulting
Date

MonthDayYear
Date
Client Name*
Home Phone
Cell Phone*
Email Address*
example@example.com
Street*
Please include Apt or Unit number
City*
State + Zip*
Facility Information

The questions that follow are about the potential or already established facility.
Street*
type N/A if you haven't found a property yet.
City
State + Zip
Does this address have an HOA?*

NoYes
What type of Residential Care Facility are you trying to open?*

Home for Individual Residential CareGroup HomeAssisted Living FacilityOther
Do you have an administrator?*

NoYes
If yes, please provide the administrator's name
Do you have a business license?*

NoYes
If yes, which issuing agency? Select all that apply.

City of Las VegasCity of HendersonClark CountyOther
Should be Empty:

Facility Information