Reservation Application
Please fill information out completely.
Personal Information
Name
First Name
Last Name
Social Security Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Marital Status
Single
Married
Divorced
Separated
Widowed
Citizen of the USA
Yes
No
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If naturalized, Certificate No:
Religion
Previous Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
US Military Service:
Yes
No
If Yes, Branch of Service:
Occupation or Trade:
Place of Employment:
Employer Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates of Employment
MM/DD/YY to MM/DD/YY
Spouse's Name:
First Name
Last Name
Is your spouse still living?
Yes
No
If yes, please provide your spouse's current address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If deceased, please provide date of death:
-
Month
-
Day
Year
Date
Number of Children:
Names of Children
Hospitalization & Medical Insurance
Hospital Preference:
Ambulance Preference:
Medicare Number:
Other Medicare Insurance:
Name of Company:
Policy Number:
Group Number:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Premium Amount
Paid By:
First Name
Last Name
V.A. Claim Number:
Name of Physician:
First Name
Last Name
Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Physician's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Specify Funeral Home
Funeral Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Funeral Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person(s) to be Notified in Case of Emergency
Emergency Contact Name
First Name
Last Name
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship
Occupation
Name of Employer:
Employer Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Power of Attorney
Power of Attorney's Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How Mail Should be Delivered
How should mail be delivered
All Mail to Resident
Personal Mail Only to Resident
Business Mail-to Name:
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Will you be receiving the newspaper?
Yes
No
Would you like to authorize for the Toe Nail Clinic?
Yes
No
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Will you be receiving cable?
Yes
No
Applicant's Financial Assets and Income
Yearly Income
Social Security
Number
Per Month Gross Amounts
Payee
First Name
Last Name
Checks Go To
First Name
Last Name
Social Security Number Which Benefits are Paid:
Pensions
Must include type of pension and address
Gross Dollar Amount:
Claim Number:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Veterans Administration
Gross Dollar Amount:
Claim Number:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company
Name of Company
Gross Dollar Amount:
Claim Number:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Other Income
Gross Dollar Amount
Describe Type:
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Rent From Real Property
Amount
Expenses to Maintain Rental Property
Dividends from Securities
Amount
Interest from Bank Accounts
Amount
Income from Annuities
Amount
Other Income
Amount
Describe:
Assets
Make sure address and account numbers are filled in and accurate.
Cash on Hand Amount
Bank Accounts
Bank Account 1 Name
Bank Account 1 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Bank Account 1 Balance
Bank Account 2 Name
Bank Account 2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Bank Account 2 Balance
Bank Account 3 Name
Bank Account 3 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Bank Account 3 Balance
Safety Deposit Box
Where?
Contents:
Stocks
Name of Stock
Shares:
Name of Broker:
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Market Value
Bonds
Name of Bond
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Real and Personal Property
We will require proof of current market value, proof of loan balance, equity or title.
Location
Type of Property:
Market Value
Mortgages Against Property:
To Whom:
Taxes
Life or Annuity Insurance
Name of Company:
Policy Number
Amount
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Present Cash Surrender Value:
Does ANYONE owe you money?
Yes
No
Person's Name:
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Amount
Do YOU owe anyone money?
Yes
No
Person's Name
First Name
Last Name
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Plan of Payment for Cost of Care at The Argyle
Own Assets and/or Income:
The information given on this reservation application is correct. I hereby apply for admission to The Argyle and give permission to the following institutions to supply the Argyle with verification of financial information supplied on this application.
Note: State and Federal Law prohibits discrimination based on race, creed, color, national origin, sex, handicap, or sponsor. A copy of Power of Attorney for health care and finances must accompany this application and must be completed with accompanying documentation PRIOR to an applicant receiving consideration for admission to The Argyle.
Applicant's Name
First Name
Last Name
Signature of Applicant or Power of Attorney
Date
-
Month
-
Day
Year
Date
Should be Empty: