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Tenant Name:_______________________________________________________ Current Address:_____________________________ Telephone: ( )__________ City:___________________________ State:__________ Zip Code:____________ Social Security Number: - - Birth Date:___________________ Name of Responsible Party or Nearest Relative:____________________________ Relationship to Applicant:______________________ Telephone: ( )__________ Address:__________________________________________________________ Street City State ZIP Is responsible party billed? _______________ If not, please provide information for financial management purposes: Financial Manager:__________________________________________________ Address:__________________________________________________________ Street City State ZIP Relationship:_______________________________________________________ Physician:_________________________________ Telephone: ( )__________ Address:__________________________________________________________ Street City State ZIP Signature of the Responsible Party:_____________________________________ Please enclose a $150, non-refundable application fee with this application. Fee is due within 30 days of receipt of this application. The fee assures your position among prospective residents. Return application or for more information, contact: Nancy Ketcham, Director Riverview Terrace Assisted Living Residence 1501 St. Luke Drive, Spencer, Iowa 51301 712.262.5932 FAX: 712.264.6705 Email: nancy.ketcham@stlukelh.com |