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PLEASE FILL OUT COMPLETELY
Move-in Fees May Apply
MAKE PAYMENT HERE
Rental Prices are Subject to Change
Click to Read Terms and Conditions
Choose Your Race
Select One
I am a White
I am a Black
I am a Hispanic
I am a Other
Choose Your Gender
Select One
I am a MALE
I am a FEMALE
I am a LGBT
Do You Have Insurance?
Select One
YES
NO
Would You Like to be Contacted by a Health Insurance Agent?
Select One
YES
NO
Are You Interested in Health & Wellness Program?
Select One
YES
NO
Would You Like to Supplement Your Income?
Select One
No
Job for Senior
Job for Disabled
Job for Anyone Else
Part-Time Job
Full-Time Job
Choose Your Military Status
Select One
Not a Veteran
I am a Veteran
Retired Veteran
Spouse of a Veteran
Choose Your Independence Status
Select One
I am an Independent Senior
I am NOT an Independent Senior
Are You Homeless?
Select One
YES
NO
Choose Your Smoker Status
Select One
I am a Smoker
I am NOT a Smoker
Choose Your Pet Status
Select One
I don't have a pet
I have a Dog
I have a Cat
Choose Your Disability Status
Select One
I am Disabled
I am NOT Disabled
OPTIONAL CHOOSE PROPERTIES
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