6. Applicant (licensee) information: Operator/management if Applicable: Street Address, City, State, Zip, Phone#: Name of legal owning entity of the Facility (exactly as registered with Oregon Secretary of State): EIN or tax identification number: Street address: City/State/ZIP: Contact name: Phone: Fax: Email: - - - - Type of business: For-profit corporation LLC Partnership Sole proprietorship LLP Tribal Not-for-profit corporation Government (please specify): Workers’ compensation carrier: Policy number: Part 2 Ownership or control interests — List the name and address for individuals and the EINs for organizations having direct or indirect ownership or controlling interest in the provider entity (see instructions for definition of ownership and controlling interest). Attach additional pages as necessary to list all officers, ownership individuals and entities with ten percent (10%) or more direct or indirect ownership. If the facility serves the Medicaid population, list all those with five percent (5%) or more direct or indirect ownership and include their Social Security numbers. EIN or Percentage Entity Name Address individual SSN of ownership type* *Entity type: In the type” enter one of the codes listed below for each individual listed: “entity 1: Sole proprietorship 2: Partnership 3: Unincorporated associations 4: Corporation 5: Government or tribal 6: Other (specify): Has any owning individual or owning entity currently or previously: Held any ownership interest in any facility (see Provided services to 1. instructions for definitions)? any individuals for which license, registration or certification was either denied, or involuntarily or voluntarily terminated during a state or federal termination process during the past five years? Yes No
6. Applicant (licensee) information: Operator/management if Applicable: Street Address, City, State, Zip, Phone#: Name of legal owning entity of the Facility (exactly as registered with Oregon Secretary of State): EIN or tax identification number: Street address: City/State/ZIP: Contact name: Phone: - - Fax: - - Email: Type of business: For-profit corporation LLC Partnership Sole proprietorship LLP Tribal Not-for-profit corporation Government (please specify): Workers’ compensation carrier: Policy number: Part 2 — Ownership or control interests List the name and address for individuals and the EINs for organizations having direct or indirect ownership or controlling interest in the provider entity (see instructions for definition of ownership and controlling interest). Attach additional pages as necessary to list all officers, ownership individuals and entities with ten percent (10%) or more direct or indirect ownership. If the facility serves the Medicaid population, list all those with five percent (5%) or more direct or indirect ownership and include their Social Security numbers. Name Address EIN or individual SSN Percentage of ownership Entity type* *Entity type: In the “entity type” enter one of the codes listed below for each individual listed: 1: Sole proprietorship 2: Partnership 3: Unincorporated associations 4: Corporation 5: Government or tribal 6: Other (specify): Has any owning individual or owning entity currently or previously: 1. Held any ownership interest in any facility (see instructions for definitions)? Provided services to any individuals for which license, registration or certification was either denied, or involuntarily or voluntarily terminated during a state or federal termination process during the past five years? Yes No
APDR-0570R.docx