Senior 62+ Wait-List Form

Last Name *

First Name *

Middle Initial

Address *

City *

State *

Zip *

Daytime Phone Number *

Family Composition:

Please complete one line for each member of the household, starting with yourself. All household members must be of 62 years of age or older.


Name	Relationship	Date of Birth	Sex	Ethnicity	Last 4 Digits of SSN	Income Source	Monthly Amount
Name	Relationship	Date of Birth Month Day Year	Sex	Ethnicity	Last 4 Digits of SSN	Income Source Employment Unemployment Social Security Pension	Monthly Amount
Name	Relationship	Date of Birth Month Day Year	Sex	Ethnicity	Last 4 Digits of SSN	Income Source Employment Unemployment Social Security Pension	Monthly Amount
Name	Relationship	Date of Birth Month Day Year	Sex	Ethnicity	Last 4 Digits of SSN	Income Source Employment Unemployment Social Security Pension	Monthly Amount

Select your preferred property *

Hawthorne Lakes Senior Residences

Bristol Place Senior

North Bend Senior Residences

Select your preferred unit *

1 Bedroom

2 Bedroom

Please choose your preferred apartment selection from the following list.

Do you have any special needs which would require a reasonable accommodation? *

Yes

(Documentation from a medical professional will be required to verify reasonable accommodation request)

If applicable, select a reasonable accommodation

Handicap Accessible

Sensory Accommodation

Do you live/work in the community? *

Yes

Date Apartment Needed *

Month

Day

Year