Bethany St. Joseph Corporation
Assisted & Senior Living Housing Application
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Previous Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Home Phone Number
*
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
Email to Notify of Openings
example@example.com
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Is there a second applicant?
Yes
No
Applicant 2 Name
First Name
Last Name
Applicant 2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant 2 Home Phone Number
-
Area Code
Phone Number
Applicant 2 Cell Phone Number
-
Area Code
Phone Number
Applicant 2 Email
example@example.com
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Select One:
Assisted Living
Independent Living
I am interested in the following Assisted Living facilities (Check all that apply):
Laurel Manor – 108 17th Ave S, Onalaska WI
Mill St. Manor – 840 Mill St, West Salem WI
Prairie Home – 620 Malin Ct, Holmen WI
Salem Terrace – 104 Lewis St, West Salem WI
Shelby Terrace – 2525 Shelby Rd, La Cross, WI
Vernon Acres, Viroqua, WI
Senior Housing With Support Services (Check all that apply)
Mill St. Manor – 840 Mill St, West Salem WI
OnaMain – 920 Main St, Onalaska WI
OnaTerrace – 1126 Main St, Onalaska WI
Prairie Home – 620 Malin Ct, Holmen WI
Salem Terrace – 104 Lewis St, West Salem WI
Welcome Home – 3600 28th St S, La Crosse WI
Windsor Place – 1020 Windsor St, La Crosse WI
Eden House – 19441 Eden Dr, Galesville WI
Friendship House – 321 Black River Ave, Westby WI
Senior Housing With Support Services (Check all that apply)
Mill St. Manor – 840 Mill St, West Salem WI
OnaMain – 920 Main St, Onalaska WI
OnaTerrace – 1126 Main St, Onalaska WI
Prairie Home – 620 Malin Ct, Holmen WI
Salem Terrace – 104 Lewis St, West Salem WI
Welcome Home – 3600 28th St S, La Crosse WI
Windsor Place – 1020 Windsor St, La Crosse WI
Eden House – 19441 Eden Dr, Galesville WI
Friendship House – 321 Black River Ave, Westby WI
Preference
Studio
One Bedroom
Two Bedroom
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Who should we contact about this application?
Applicant 1
Applicant 2
A family member
Family Member Name
First Name
Last Name
Family Member Phone Number
-
Area Code
Phone Number
Family Member Email
example@example.com
Were you referred to BSJ Assisted or Independent Living by a current tenant or Employee of BSJ Corp?
Yes
No
Please enter their name.
Additional Information
Signature
Submit
Equal Housing Opportunity All programs and services shall be made available without regard to Race, Creed, Gender, National Origin or Other Unlawful Grounds
Should be Empty: