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Golden Dwellings Senior Co- Living Pre-screening Application
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* Indicates required question
Client's Full Name
*
Your answer
Referrer Name / Company Name:
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Contact Details
(Phone Number & Email)
*
Your answer
When are you looking to move in?
*
Your answer
Gender
*
Male
Female
How much rent can you afford to pay a month?
*
Your answer
Are you able to live independently? (bathe yourself, cook for yourself, and use the bathroom)
*
Yes
No
Maybe
Do you take medication? If so, do you have a problem with receiving it ?
*
Yes
No
Maybe
Do you have family or a support team?
Your answer
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