Nivory Independent Living Community

Nivory Independent Living Community

Resident Intake Application
Resident Information
Full legal Name *
Preferred Name
Date of Birth *

MonthDayYear
Date
Age
SSN (Last 4 Digits Only)*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Emergency Contact Name*
Relationship *
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Housing Information
YesNo
Jail/PrisonTreatment FacilityHospitalShelterOther
If Other, please explain
Desired Move-In Date*

MonthDayYear
Date
Income & Payment Information
EmploymentSSI/SSDIVeteran BenefitsFamily SupportOther
Other income source
Monthly Income Amount *
YesNoWith Assistance
Medical & Support Needs
YesNo
Please explain medical conditions if Yes
YesNo
YesNo
Please explain assistance needed if Yes
Community Living Agreement
YesNo
YesNo
Legal & Supervision
YesNo
Officer Name & Phone Number
YesNo
Personal References
Reference #1 Name, Phone # & Relationship
Reference #2 Name, Phone # & Relationship
Acknowledgment & Signature

Certification & Signature
Resident Signature *

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Date Signed

MonthDayYear
Date
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Type option 1Type option 2Type option 3Type option 4
Medical Conditions or Allergies
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Email
example@example.com
Emergency Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Should be Empty:

Nivory Independent Living Community

Resident Information

Emergency Contact Information

Housing Information

Income & Payment Information

Medical & Support Needs

Community Living Agreement

Legal & Supervision

Personal References

Acknowledgment & Signature

Emergency Contact Information