Bethel Lutheran Nursing and Rehabilitation Center

Assisted Living Online Application

Thank you for you interest in Bethel Assisted Living Center. By completing this application, you are confirming your interest in an apartment in our Assisted Living Center. This information will be held in strictest confidence. Click the submit button when you have completed the application and we will contact you as soon as possible.

I. GENERAL

* 1. Name:
2. Name:
* Current Home Address:
* City:
* State:
* Zip:
* Home Phone:
Cell Phone:
Email:
* Birth Date: 1.	* Age:
Birth Date: 2.	Age:

II. CONTACT PERSON(CHILD OR CLOSEST RELATIVE)

Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:

III. RENT

Current base rentals are:
(Please check the appropriate boxes below)

$3,050/month for a one bedroom unit (593 sq. ft)

$3,400/month for a two bedroom unit (821 sq. ft)

$900/month (second occupant)

I have sufficient income to cover current rent rate plus any additional services at Bethel Assisted Living Center for years.

I understand and agree the foregoing application is not a contract or reservation for residence, in that by completing this application there is no assurance of tenancy. Nothing contained herein is binding on either party until a Lease Agreement has been signed by the parties involved.