How to Apply

Title -Choose- Mr. Mrs. Ms. Miss Dr. Rev. Other

Male Female *

Given Name(s): *

Surname(s): *

Email: *

Date of Birth -Day- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -Month- January February March April May June July August September October November December -Year- 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 *

Address: *

City: * -Province/State- Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Fed. States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Is. Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Country: (Only for International)

Postal Code/ZIP: *

Phone: *

Marital Status: -Marital Status- Common Law Divorced Married Separated Single Widowed Other

Are you an abstainer? (i.e., you do not drink alcoholic beverages) Yes No

Are you a smoker? Yes No

Do you have any physical or other limitations that would prohibit you from living independently in the building? If yes, please specify:

What is your present rent? /month

How did you learn about Shepherd Village?

Is parking (above ground) required? Yes No

Type of accommodation preferred: -Choose- Bachelor 1 Bedroom 2 Bedroom (couples only) Any

Denomination/Faith group:

Clergy/Religious leader name:

Name (First/Last):

Telephone:

Address:

City: Province/State -Choose- Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Fed. States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Is. Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Country: (Only for International)

Postal Code/ZIP:

Relationship -Choose- Brother Sister Son Daughter Uncle Aunt Friend Neighbour Power of Attorney Other

Title -Choose- Mr. Mrs. Ms. Miss Dr. Rev. Other

Male Female *

Given Name(s): *

Surname(s): *

Email: *

Date of Birth -Day- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -Month- January February March April May June July August September October November December -Year- 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 *

Address: *

City: * -Province/State- Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Fed. States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Is. Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Country: (Only for International)

Postal Code/ZIP: *

Phone: *

Marital Status: -Marital Status- Common Law Divorced Married Separated Single Widowed Other

Are you an abstainer? (i.e., you do not drink alcoholic beverages) Yes No

Are you a smoker? Yes No

Do you have any physical or other limitations that would prohibit you from living independently in the building? If yes, please specify:

What is your present rent? /month

How did you learn about Shepherd Village?

Is parking (above ground) required? Yes No

Type of accommodation preferred: -Choose- Bachelor 1 Bedroom 2 Bedroom (couples only) Any

Denomination/Faith group:

Clergy/Religious leader name:

Name (First/Last):

Telephone:

Address:

City: Province/State -Choose- Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Fed. States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Is. Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Country: (Only for International)

Postal Code/ZIP:

Relationship -Choose- Brother Sister Son Daughter Uncle Aunt Friend Neighbour Power of Attorney Other