FOR OFFICE USE ONLY:

APARTMENT #_________

APARTMENT SIZE______

MOVE IN DATE_________

RENTAL AMOUNT______

SECURITY DEPOSIT_____

APPLICATION FEE______

APPLICATION FOR RESIDENCY

MR.( ) MRS.( ) MISS( )__________________________________________________________________

LAST FIRST MIDDLE

PRESENT ADDRESS____________________________________________________________________

NUMBER STREET CITY

________________________________________________________________

STATE ZIP COUNTY

TELEPHONE NUMBER_________________________________________________________________

SOCIAL SECURITY NUMBER___________________________________________________________

DATE OF BIRTH_______________________________________________________________________

ARE YOU RETIRED ( ) YES ( ) NO OCCUPATION_______________________________________

MARITAL STATUS_____________________________________________________________________

IS THERE ANY MEDICAL CONDITION THAT MIGHT PREVENT YOUR BEING ACCEPTED AS A RESIDENT OF VILLA ROSE? ( ) NO ( ) YES,

PLEASE EXPLAIN THE CONDITION.__________________________________________________

___________________________________________________________________________________

PERSON TO CONTACT IN CASE OF EMERGENCY (PLEASE PROVIDE TWO)

RESIDENT REPRESENTATIVE:

NAME__________________________________________________RELATION____________________

ADDRESS_____________________________________________________________________________

HOME PHONE#____________________________WORK #____________________________________

NAME__________________________________________________RELATION____________________

ADDRESS_____________________________________________________________________________

HOME PHONE#____________________________WORK #_____________________________________

PHYSICIAN______________________________________________PHONE #_____________________

ADDRESS_____________________________________________________________________________

HOSPITAL PREFERENCE___________________________________PHONE #_____________________

ARE YOU LICENSED TO DRIVE A CAR? ( ) YES ( ) NO

ARE YOU BRINGING A CAR WITH YOU TO VILLA ROSE? ( ) YES ( ) NO

IF YES; AUTO MAKE AND YEAR_________________________________________________

LICENSE PLATE________________________________________________________________

ACTIVITY INFORMATION:

WHAT APPEALS TO YOU MOST ABOUT VILLA ROSE?_______________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

WHAT ARE YOUR HOBBIES?______________________________________________________________

WHAT ARE YOUR SPECIAL INTEREST? ( ) SPORTS ( ) LITERATURE ( ) PETS ( ) TV

( ) CHURCH ACTIVITIES ( ) MUSIC ( ) CHILDREN ( ) CREATIVE CRAFTS ( ) TRAVEL

( ) POLITICS ( ) CURRENT EVENTS

( ) OTHER____________________________________________________________________________

RELIGIOUS AFFILIATION___________________________________PASTOR_______________________

PLACE OF MEMBERSHIP__________________________________________________________________

HOW DID YOU LEARN ABOUT VILLA ROSE? PLEASE CHECK THE APPROPRIATE BOX:

 ADVERTISEMENT  DIRECT MAIL  BROCHURE  EVENT  RESIDENT

 FRIEND  SIGN/DRIVE BY  PROFESSIONAL REFERRAL ________________

CAN YOU DOCUMENT THAT YOU CAN PAY THE MONTHLY FEE?

( ) YES ( ) NO

I AGREE TO HAVE A HEALTH ASSESSMENT COMPLETED PRIOR TO MOVE IN.

( ) YES ( ) NO

SIGNATURE OF APPLICANT DATE

SIGNAGURE OF APPLICANT DATE

We frequently document events and activities at Villa Rose by taking pictures of residents and their families. Some pictures taken on occasion may be published on our website. We will never publish information about any of our residents that would jeopardize their safety. For legal purposes, we ask that you sign the following release form before any pictures can be used.

MODEL RELEASE

For valuable consideration, I hereby irrevocably consent to and authorize the use and reproduction by Villa Rose, or anyone authorized by Villa Rose, of any and all photographs which you have this day taken of me, negative or positive, proofs of which are hereto attached, for any purpose whatsoever, without further compensation to me. All negatives and positives, together with the prints shall constitute Villa Rose property, solely and completely.

Model: ____________________________________________________________________________

Address: ___________________________________________________________________________

Witnessed By:_______________________________________________________________________

Date:______________________________________________________________________________