M-SARR Membership Application
Type of Membership:
*
Please Select
Add Recovery Residence (1)
Add Recovery Residence (2)
Add Recovery Residence (3)
How did you hear about M-SARR?
Section I: Member Information
(information on the organization or individual operating a recovery residence)
Applicant or Business Name:
Principal Business Contact Name:
Title:
Street address
Street address line 2
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
Phone number
E-mail Address
Fax:
Website Address:
Facebook/ Twitter (or other social media) Address:
Is your organization currently registered to conduct business in the State of Maryland?
Yes
No
Pending
Type of Organization:
Please Select
Corporation
Non-Profit
Other
Total Number of Recovery Residences owned/operated by organization
*
Number of Single Family Residence(s)10 Beds or less (SFR)
*
Number of Multi-Unit Dwelling/ Apartments (MUA)
*
Facility (FAC)
*
Total Resident Capacity:
Total Resident Capacity SFR:
Total Resident Capacity MUA:
Total Resident Capacity FAC:
Is your organization equipped to provide reasonable accommodations for persons with disabilities?
Yes
No
Section II: Recovery Residence Information
New Property #1
Date residence was established:
-
Month
-
Day
Year
Date
Telephone Number
Contact Name
Street address
Street address line 2
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
Property Ownership:
Please Select
Owns Property
Leases from Third Party
Leases from Related Person/ Entity
Other
E-mail
Is this property licensed by the State of Maryland to provide services for:
Mental Health
Substance Use Disorder
Behavioral Health
None of the Above
Other
List types of reasonable accommodations for persons with disability provided.
Number of Bedrooms:
Age Range:
18-24
25- 44
45-64
65+
Type of Structure:
Single Family Residence- 10 Beds or less
Multi-Unit Dwelling/ Apartments
Facility (Over 10 beds)
Population Served:
Women
Men
Co-Ed
Re-Entry
Medication Assisted Recovery (MAR)
Parents and children
LGBTQI
Youth (under 19 years old)
Senior Citizen (62+)
Laundry on Site:
Yes, Coin Operated
Yes, Included in Resident Fee
No
If leased, do you have written permission from property owner to operate a recovery residence?
Yes
No
Other
Basic Weekly Resident Fee
Is Food included?
Yes
No
Additional Fees? Please be specific.
New Property #2
Date residence was established:
-
Month
-
Day
Year
Date
Telephone Number
Contact Name
Street address
Street address line 2
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
Property Ownership:
Please Select
Owns Property
Leases from Third Party
Leases from Related Person/ Entity
Other
E-mail
Is this property licensed by the State of Maryland to provide services for:
Mental Health
Substance Use Disorder
Behavioral Health
None of the Above
Other
List types of reasonable accommodations for persons with disability provided.
Number of Bedrooms:
Number of Bathrooms:
Age Range:
18-24
25- 44
45-64
65+
Type of Structure:
Single Family Residence- 10 Beds or less
Multi-Unit Dwelling/ Apartments
Facility (Over 10 beds)
Population Served:
Women
Men
Co-Ed
Re-Entry
Medication Assisted Recovery (MAR)
Parents and children
LGBTQI
Youth (under 19 years old)
Senior Citizen (62+)
Laundry on Site:
Yes, Coin Operated
Yes, Included in Resident Fee
No
If leased, do you have written permission from property owner to operate a recovery residence?
Yes
No
Other
Basic Weekly Resident Fee
Is Food included?
Yes
No
Additional Fees? Please be specific.
New Property #3
Date residence was established:
-
Month
-
Day
Year
Date
Telephone Number
Contact Name
Street address
Street address line 2
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
Property Ownership:
Please Select
Owns Property
Leases from Third Party
Leases from Related Person/ Entity
Other
E-mail
Is this property licensed by the State of Maryland to provide services for:
Mental Health
Substance Use Disorder
Behavioral Health
None of the Above
Other
List types of reasonable accommodations for persons with disability provided.
Number of Bedrooms:
Number of Bathrooms:
Age Range:
18-24
25- 44
45-64
65+
Type of Structure:
Single Family Residence- 10 Beds or less
Multi-Unit Dwelling/ Apartments
Facility (Over 10 beds)
Population Served:
Women
Men
Co-Ed
Re-Entry
Medication Assisted Recovery (MAR)
Parents and children
LGBTQI
Youth (under 19 years old)
Senior Citizen (62+)
Laundry on Site:
Yes, Coin Operated
Yes, Included in Resident Fee
No
If leased, do you have written permission from property owner to operate a recovery residence?
Yes
No
Other
Basic Weekly Resident Fee
Is Food included?
Yes
No
Additional Fees? Please be specific.
Section V: Applicant Affidavit and Signature
*
Applicant hereby requests membership in the Maryland State Association of Recovery Residences (M-SARR) and is willing to fully participate in M-SARR sponsored events/ activities.
*
I have fully read, understand, and agree to abide by M-SARR established “Standards and Code of Ethics" policies
By checking the box below and submitting this application, 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. This form is being submitted by
*
Please check the box in order to submit your application
Application and Recovery Residence Inspection payments are required prior to application review and can be made at this time through PayPal. Resident inspection fees are automatically calculated based on the type of structure and capacity of your organization. To complete your application submission with payment, click "Proceed to Checkout".
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Add Recovery Residence
$
100.00
$100.00 Per Recovery Residence
Inspection Fee- per Bed
$
15.00
15.00 per Bed
Total
$
0.00
Proceed to Checkout
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