Application – Thompson Gardens

Applicant

Name*

Date of Birth*

Email*

Church Affiliation*

State of Health

Excellent
Good
Fair

Are you able to live independently?

Yes
No

Please list any support agencies that you currently utilize to enable you to live independently

Please list any physical assists that you require (i.e. walker, wheelchair, etc.) in order to live independently

Co-Applicant

Name*

Date of Birth*

Church Affiliation*

State of Health

Excellent
Good
Fair

Are you able to live independently?

Yes
No

Please list any support agencies that you currently utilize to enable you to live independently

Please list any physical assists that you require (i.e. walker, wheelchair, etc.) in order to live independently

Size of Apartment Preferred

Studio

Current Address*

Home Phone Number*

Alternate Phone Number*

Do you own or rent?

Own
Rent

Length of time at this address*

Landlord contact information

Previous Address #1

Did you own or rent?

Own
Rent

Length of time at this address

Landlord contact information

Previous Address #2

Did you own or rent?

Own
Rent

Length of time at this address

Landlord contact information

References

Personal reference #1

Include contact information

Personal reference #2

Emergency reference #1

Emergency reference #2

Include 2 phone numbers & relationship

The Board of Directors of the Moore Presbyterian Foundation undertakes to treat the information provided by the applicant(s) in a confidential manner. Completed applications will be reviewed by the Board. Upon Board approval the applicant(s) will then be placed on the waiting list.

By clicking the button below, I/we certifies that the above information is complete and correct.

This application is restricted for use of the Moore Presbyterian Foundation Board of Directors only.

THOMPSON GARDENS (Owned Operated by the Moore Presbyterian Foundation) Life Lease Apartment Application

Applicant

Co-Applicant

Previous Address #1

Previous Address #2

References