Resident Application Form

Resident Application Form
Are you applying to live at THE MANKOWSKI HOMES or for housing support from MANKOWSKI INTERNATIONAL?*

THE MANKOWSKI HOMESMANKOWSKI INTERNATIONAL
How did you find out about us ?

Personal Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Mobile Phone

Country CodeMobile Number
Email*
example@example.com
Date of Birth*

MonthDayYear
Gender

MaleFemale
Are you married, widowed, divorced, or single?
Birthplace
Citizenship (country)*
If your citizenship is other than United States, are you able to obtain a permanent United States visa?

YesNoDon't know

Christian Science Practice
How long have you been an active student of Christian Science?*
How long have you advertised in The Christian Science Journal as a Christian Science Practitioner?*
How long have you advertised in The Christian Science Journal as a Christian Science Nurse?*
Christian Science PractitionerChristian Science Nurse
Are you currently advertising in The Christian Science Journal?*

YesNo
If you have ever withdrawn or been removed from listing in The Christian Science Journal, kindly explain in full.
When did you receive Christian Science Primary Class instruction?*
Who was your Christian Science Primary Class teacher?*
What year did you join The Mother Church?*
To which branch church or Society do you currently belong?
Year joined
Please list the last three Christian Science branch churches or Societies where you have been a member, the approximate year joined, and the reason for leaving.
Please list the various ways in which you have served any Church of Christ, Scientist over the years*
Do you intend to continue active branch church or Society participation?*

YesNo
It is assumed that, as a practicing Christian Scientist, you are free from the use of tobacco, drugs, and intoxicants. Is this true?

YesNo
Please explain

If A Special Need Arose

Please provide names and contact information of those who would help if an emergency or a special need arose (including any adult children). MANKOWSKI INTERNATIONAL applicants only need to provide two contacts.
Emergency Contact 1
Full Name*
Telephone*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Relationship*
Supportive of Christian Science?*
Emergency Contact 2
Full Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Relationship
Supportive of Christian Science?
Emergency Contact 3
Full Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Relationship
Supportive of Christian Science?

References

Please list three references that are members of The Mother Church who are not related to you, including one Journal-listed Christian Science practitioner acquainted with you. Please list the Christian Science Practitioner first.
Refrence Contact 1
Christian Science Practitioner’s Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Telephone
Please enter a valid phone number.
How acquainted ?*
Reference Contact 2
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Telephone
Please enter a valid phone number.
How acquainted ?*
Reference Contact 3
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Telephone
Please enter a valid phone number.
How acquainted ?*

Please disclose any present indebtedness more than $1,000 US, 1,000 EURO, £500 GBP

Comments
Please comment on anything in this application you may wish to explain or discuss further:
Why are you applying to live at THE MANKOWSKI HOMES or for support from MANKOWSKI INTERNATIONAL?

Verification/Approval Signature
UNDER PENALTIES OF PERJURY, I declare that, to the best of my knowledge and belief, the answers to the financial statements made in this application are a true, correct, and complete statement of my financial condition.

I hereby grant permission to the WINIFRED STUART MANKOWSKI FOUNDATION and its agents to contact the references and to verify such information as is deemed necessary to process this application. I further attest to the fact that all I have stated in this application is correct to my best knowledge and belief.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Personal Information