Resident Application Form

Resident Application Form
Are you applying to live at THE MANKOWSKI HOMES or for housing support from MANKOWSKI 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.Format: (000) 000-0000.
Mobile Phone

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearMM-DD-YYY
Gender
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?

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?
Are you currently advertising in The Christian Science Journal?
If you have ever withdrawn or been removed from listing in The Christian Science Journal, kindly explain in full.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?
It is assumed that, as a practicing Christian Scientist, you are free from the use of tobacco, drugs, and intoxicants. Is this true?
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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.
Reference 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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate (MM-DD-YYYY)
Should be Empty:

Personal Information