APPLY FOR RETIREMENT LIVING

PERSONAL DETAILS

Title:
Other:
Surname*:
Given names*:

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

Phone:
Mobile*:

Email*:

Address*:

Postal address:


SECOND CONTACT

Surname:
First name:
Phone:
Mobile:

Email:

Postal address:


WAITING LIST ENTRY

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.*