HOUSING APPLICATION

E-mail Address: * Name Date of Birth Place of Birth Current Address City State Marital Status SingleMarriedDivorcedSeparatedWidowed Health Insurance Pharmacy Assistance Card Yes No Name of Physician Address of Physician Phone Number of Physician: If not seen by Physician, where do you go for medical treatment Address Do you have any allergies? If you have allergies, what are you allergic to? Financial Source: Gross Monthly Income Do you own real estate property? Yes No Do you own stocks or bonds? Yes No If, yes to the previous questions, please list: Name of Life Insurance Company? Do you have a registered Will? Yes No Do you have an Advance Directive? Yes No Do you have a Living Will? Yes No Do you have a Power of Attorney or someone designated to act in your behalf? Yes No Name of Power of Attorney Relation to you Address City/State/Zip Phone Number Work Home Cell Phone Email Why type of activities or hobbies do you enjoy? What is the name, church, and telephone number of your Pastor or church representative? * Required

* Completion of this form constitutes your "electronic signature"