|
Clawson Manor
255 W. Fourteen Mile Rd.,
Clawson, MI 48017
(248) 435-5650
Fax (248) 435-0840
www.clawsonmanor.org
All Information
Will be Kept Confidential
Clawson Manor is
owned and operated by New Life Inc., a Michigan Non-Profit
Corporation, which is part of the East Michigan Conference of
the Free Methodist.
CRITERIA FOR
RESIDENCY
-
You (or your spouse)
must be 62 years of age or older. If handicapped, the
minimum age requirement does not apply.
-
You must be in
reasonable good health, able to care for yourself and
maintain your own apartment in good order.
GENERAL INFO: Please Print
Last Name: ______________________________
First Name: ____________________________
Address:________________________________________________________________________
City: ___________________________
State___________________ Zip Code: _______________
Phone: _(_______)_______________________
Date of Birth _____/______/_______
SSN # _______-__________-___________
MARITAL STATUS:
Widow(er)
____ Divorced _____
Single _____ Separated ______
If married, name
of spouse:
________________________________________________________
Birthdate of
spouse: ญญ_____-_____-_______ SSN#______-______-_______
APARTMENT
INFO:
Type of
Apartment desired:
Efficiency
(374 sq. ft.) _____ Bedroom (500 sq. ft.)
_____ Bedroom (750) sq. ft. ____
Clawson Manor
has 15 floors. Identify the floor above which you will NOT
consider an apartment: ______
Will you keep an
automobile: Yes _____ No _____ If so,
Make/Model
_______________________ Year____________
License
#________________
HEALTH:
Do you represent
and certify that you have no physical conditions, which at the
time you take occupancy of your apartment, will affect your
ability to maintain your apartment in the same condition as when
you move in, or take care of essential personal needs? Yes
_____ No _____
Do you smoke?
Yes _____ No ______
Do you have a
problem with the over consumption of alcoholic beverages or
controlled substances?
Yes _____ No _____
PERSONAL:
Do you have any
special hobbies or interests? ________________________
_______________________________________________________________
Identify any
religious affiliation: ______________________________________
Please provide 3
or more Personal References other than your Pastor, Rabbi or
Doctor.
Name
Address
Phone
1.
_____________________________________________________________________________
2.
_____________________________________________________________________________
3.
_____________________________________________________________________________
Date:
_____/_____/______ Signature:
_____________________________ |