Arbutus Park Retirement Community
Cottage Application

Your Anitcipated Move Date
Name Date of Birth
Present Address Current Phone
Marital Status Single           Married         Widowed          Divorced
Spouse's Name
Social Security Number
Assets Real Estate Owned
  Type
  Location
  Appraised Value
LEGAL REPRESENTATION
Durable Power of Attorney Name
  Address Phone
Financial Power of Attorney Name
  Address Phone
Living Will Do you have a living will? Yes No
Family Information

(Please list all Children, close relatives or friends)
Funeral Home Address Phone
  Do you have an Irrevocable Burial Fund?        Yes No
  Cemetary
  Location
Church Affiliation Church
  Pastor
  Address Phone
I Understand that Arbutus Park Retirement Community retains the right to accept or reject any application consistent with the law. I certify that all of the information submitted on this applicantion is true and correct, and I understand the submission of false information may constitute grounds for rejection of this application or my discharge after admission. By indicating my email address below, I thereby execute this document.

Date: Current Email

                   Confirm Email Address