Web Listing Subscription Form

1. View sample.
2. Submit one form for each facility.
3. Read photo suggestions page.

Name of Home:
Administrator:
Other contact:
Address:
City:	Zip:
E-mail:
Type of Home:	RCFE (1-10 beds) Assisted Living Dedicated Alzheimers
No. of beds:
Year established:
Best Contact #s:	#1cellpagerhomefacility
	#2cellpagerhomefacility
If your facility has a website, list it here:
Description:
Testimonials:
	Please select one of the following:
	Homes already visited by Connections (no listing fee)
	I will be sending photos via e-mail. I will be mailing the photos with a $50 check for photo processing payable to Connections Referral Service, Inc. addressed to Connections Referral Service- Weblisting at 2658 Griffith Park Blvd #224, LA, CA 90039. Connections has already taken photos of my facility. New Homes (listing fee): I am sending digital photos via e-mail (see photo submittal guidlines), a signed Connections contract and the $49 new home listing fee payable to Connections Referral Service, Inc. addressed to Connections Referral Service- Weblisting at 2658 Griffith Park Blvd #224, LA, CA 90039. I will include as well the standard I do not have access to digital photos and will mail photos to Connections, the signed Connections contract and a $99 check ($49 listing fee and $50 photo processing fee) payable to Connections Referral Service, Inc. addressed to Connections Referral Service- Weblisting at 2658 Griffith Park Blvd #224, LA, CA 90039. The Web Listing Agreement: The initial set-up is free. The annual web listing fee ($300) is paid each year we place a client in your facility. No additional fees are due for additional resident placements within the same calendar year. No annual fee is due if we do not successfully place a resident within a calendar year. The web listing fee is in additional to the normal (50% of one month's charges) Connection's placement fee.  I agree to the web listing terms of agreement.