Application for Housing - SEM Terrace, Inc.

SEM Terrace, Inc. Application for Housing

5371 South Milford Rd. Milford, OH 45150 (513) 248-1140

Dear Prospective Resident:

Thank you for your interest in our community!

SEM Terrace is a senior congregate living facility with private patios for each room. These rooms are designated for persons aged 62 or older.

If you would like to put your name on our waiting list and have information sent to you simply fill out this application and mail it to us at: SEM Terrace, 5371 S. Milford Road, Milford, OH 45150 or you may email it to us at semterrace@semterrace.org. Please visit our website at www.semterrace.org for more information on our facility.

APPLICANT'S NAME(S)

CURRENT ADDRESS

HOME PHONE

ALT. PHONE

DATE OF BIRTH

DATE OF BIRTH (SPOUSE)

DO YOU HAVE ANY PETS? YES, NO. IF YES, WHAT KIND__

PREVIOUS RENTAL HISTORY:

NAME OF YOUR PRESENT LANDLORD (IF APPLICABLE):

ADDRESS

PHONE NUMBER

HOW LONG HAVE YOU LIVED AT THIS ADDRESS?

REASON FOR LEAVING:

Emergency Contact:

NAME

Address

City

US States

Zip

Phone: Home / Work /Cell 2

Second Emergency Contact:

Name

Address

City

US States

Zip

Phone: Home / Work / Cell

Name of person with power of attorney

Address

City

US States

Zip

Phone: Home / Work / Cell

Funeral Home

Vehicle Make / Model / Color / License #

Hobbies or Special interest

HOW DID YOU HEAR ABOUT SEM TERRACE?

APPLICANT SIGNATURE:

Date

CO APPLICANT SIGNATURE:

Date

SEM Terrace, Inc. Application for Housing

5371 South Milford Rd. Milford, OH 45150 (513) 248-1140

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