APPLY FOR RETIREMENT LIVING

    PERSONAL DETAILS

    Title:

    Other:

    Surname*:

    Given names*:

    Your date of birth* (DD-MM-YYYY):

    Phone:

    Mobile*:

    Email*:

    Address*:

    Postal address:

    SECOND CONTACT

    Surname:

    First name:

    Phone:

    Mobile:

    Email:

    Postal address:

    WAITING LIST ENTRY

    1 bedroom

    2 bedroom

    3 bedroom

    As soon as possible

    Within 5 years

    After 5 years

    Are you seeking ‘Rental Only’ Accommodation? (Note: Only 1 Bedroom Units available)*: NoYes

    Other comments/requirements:

    PRIVACY STATEMENT

    Glengollan Village is collecting the information on this form for the purpose of processing your application and assessing the level of care appropriate to your needs. The information collected on this form will be stored securely on our data base and will only be used for this specific purpose. It will not be disclosed to any individual or organisation. A copy of the Glengollan Privacy Policy Collection statement is available on request.

    I wish to apply for an Independent Living Unit at Glengollan Village. I understand that a unit will only be made available to me after I have had a further interview with the Retirement Village Manager.*