John H. Whitaker Place

Application for Residency

General Information:

Name ________________________________ Social Security Number __________________Tel.#______________

Address__________________________________ City____________________ State ________ Zip_____________

How long at this address?_______________ Rent Own Do you have an automobile? Yes No

Current or former occupation ______________________________________________________________________

Date of Birth ____________________ Marital Status: Single Married Widowed Divorced

Will an additional household member be occupying the unit with you? Yes No If yes, please provide:

Name ________________________________________ Social Security Number ____________________________

Date of Birth ____________________ Relationship to you ___________________________________________

How did you hear about us? _______________________________________________________________________

If you have leased housing in the past three years, please provide the following information for each location:

Landlord’s Name ______________________________ Landlord’s Telephone _____________________________

Landlord’s Address _____________________________ City _________________ State _______ Zip __________

Address of the Rental Property ___________________________________________________ Dates __________

Landlord’s Name ______________________________ Landlord’s Telephone _____________________________

Landlord’s Address _____________________________ City _________________ State _______ Zip __________

Address of the Rental Property ____________________________________________________ Dates __________

Are you or anyone in your household currently a full-time student, or planning to be a full-time student within the next 12 months? Yes No If so, who? ________________________________________________

Have you or a member of your immediate household ever been convicted of a felony? Yes No

Type of unit desired: Studio Apartment One bedroom Apartment Two bedroom Apartment

John H. Whitaker Place contains a limited number of handicap accessible apartments. Do you think you need one? Yes No

John H. Whitaker Place offers a number of personal care services as part of our assisted care community program. Please indicated the areas we may be able to assist you, as appropriate:

How do you enjoy spending your leisure time? ______________________________________________________________________________________________________________________________________________________

Name _________________________________________________ Telephone _______________________________

Address _____________________________________ City ______________________ State ______ Zip ________

Your Physician’s Name _________________________________ Telephone ______________________________

Address ______________________________________________ City ______________ State _______ Zip _____

Hospital Preference _____________________________________________________________________________

I understand and agree that a $500 deposit is required to reserve the unit of choice and will be applied to the first month’s rent. Also, the deposit is fully refundable if I/We withdraw the application from consideration up until 30 days before the occupancy date. The information is true and complete to the best of my knowledge. I understand that providing false information may be grounds for denial of my application. I authorize the management to investigate and verify all information provided which shall remain confidential.

Signature of Applicant ____________________________________________ Date ___________________________

Signature of Co-Applicant _________________________________________ Date ___________________________

Please mail this completed application, financial form and your $500 deposit to:



Application for Residency General Information: Name ________________________________ Social Security Number __________________Tel.#______________ Address__________________________________ City____________________ State ________ Zip_____________ How long at this address?_______________ Rent Own Do you have an automobile? Yes No Current or former occupation ______________________________________________________________________ Date of Birth ____________________ Marital Status: Single Married Widowed Divorced Will an additional household member be occupying the unit with you? Yes No If yes, please provide: Name ________________________________________ Social Security Number ____________________________ Date of Birth ____________________ Relationship to you ___________________________________________ How did you hear about us? _______________________________________________________________________ If you have leased housing in the past three years, please provide the following information for each location: Landlord’s Name ______________________________ Landlord’s Telephone _____________________________ Landlord’s Address _____________________________ City _________________ State _______ Zip __________ Address of the Rental Property ___________________________________________________ Dates __________ Landlord’s Name ______________________________ Landlord’s Telephone _____________________________ Landlord’s Address _____________________________ City _________________ State _______ Zip __________ Address of the Rental Property ____________________________________________________ Dates __________ Are you or anyone in your household currently a full-time student, or planning to be a full-time student within the next 12 months? Yes No If so, who? ________________________________________________ Have you or a member of your immediate household ever been convicted of a felony? Yes No Residential Information: Type of unit desired: Studio Apartment One bedroom Apartment Two bedroom Apartment John H. Whitaker Place contains a limited number of handicap accessible apartments. Do you think you need one? Yes No John H. Whitaker Place offers a number of personal care services as part of our assisted care community program. Please indicated the areas we may be able to assist you, as appropriate: Independent Would appreciate some assistance Bathing ____ ____ Dressing ____ ____ Grooming ____ ____ Toileting ____ ____ Walking ____ ____ Eating ____ ____ Medication Assistance ____ ____ Laundry ____ ____ How do you enjoy spending your leisure time? ______________________________________________________________________________________________________________________________________________________ Emergency Information: Person to contact in case of emergency: Name _________________________________________________ Telephone _______________________________ Address _____________________________________ City ______________________ State ______ Zip ________ Your Physician’s Name _________________________________ Telephone ______________________________ Address ______________________________________________ City ______________ State _______ Zip _____ Hospital Preference _____________________________________________________________________________ I understand and agree that a $500 deposit is required to reserve the unit of choice and will be applied to the first month’s rent. Also, the deposit is fully refundable if I/We withdraw the application from consideration up until 30 days before the occupancy date. The information is true and complete to the best of my knowledge. I understand that providing false information may be grounds for denial of my application. I authorize the management to investigate and verify all information provided which shall remain confidential. Signature of Applicant ____________________________________________ Date ___________________________ Signature of Co-Applicant _________________________________________ Date ___________________________ Please mail this completed application, financial form and your $500 deposit to: John H. Whitaker Place Assisted Care Community P.O. Box 2032 Concord, NH 03301