Test Form Component - Arbor Acres

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Name*

First Name* Last Name*

Address

City

State

ZIP

Phone Number

Phone Type

Email*

Inquiry About

How did you hear about us?

Inquiry For*

Who is this inquiry for?*

First Name Last Name

How are you related to this person?*

How can we help you?

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Comments

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Please choose TWO date/time options to participate in a focus group to discuss our employee culture. Thank you contributing to the improvement of Arbor Acers' culture!

You will be emailed with the final schedule. Employees will NOT be put in a focus group with their manager or supervisor. You should feel comfortable sharing your honest opinion and experience of working at Arbor Acres.

Contact Details

Name*

First Last

Department

First Choice*

MON 10/16: Robinson Hall – 7:15am

MON 10/16: Gathering Place – 9am

MON 10/16: Annie’s Kitchen – 10:30am

MON 10/16: Gathering Place – 1pm

MON 10/16: Gathering Place – 2:30pm

MON 10/16: Robinson Hall – 4pm

TUE 10/17: Robinson Hall – 7:15am

TUE 10/17: Gathering Place – 9am

TUE 10/17: Annie’s Kitchen – 10:30am

TUE 10/17: Gathering Place – 1pm

TUE 10/17: Gathering Place – 2:30pm

TUE 10/17: Robinson Hall – 4pm

Second Choice*

MON 10/16: Robinson Hall – 7:15am

MON 10/16: Gathering Place – 9am

MON 10/16: Annie’s Kitchen – 10:30am

MON 10/16: Gathering Place – 1pm

MON 10/16: Gathering Place – 2:30pm

MON 10/16: Robinson Hall – 4pm

TUE 10/17: Robinson Hall – 7:15am

TUE 10/17: Gathering Place – 9am

TUE 10/17: Annie’s Kitchen – 10:30am

TUE 10/17: Gathering Place – 1pm

TUE 10/17: Gathering Place – 2:30pm

TUE 10/17: Robinson Hall – 4pm

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Phone

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Please complete one application per person.

Contact Information

First Last

Your Address

Address City State ZIP Code

Preferred Method of Contact

Phone Number*

Phone Type

Email*

Email Confirm Email

Personal Information

Date of Birth

Month

Day

Year

Marital Status

Gender

Male

Female

Prefer Not to Say

Other

Spouse/Partner's Name

Prior Occupation(s)

Tell us more about your desired accommodations:

Apartments

Learn more about our apartment options.

Stockton:

A (991 sq. ft.)

B (1160 sq. ft)

C-1 (1217 sq. ft)

C-2 (1397 sq. ft)

C-3 (1500 sq. ft)

D-1 (1592 sq. ft)

D-2 (1602 sq. ft)

D-3 (1728 sq. ft)

Aldersgate Square

Aldersgate Square:

Duo (1546 sq. ft.)

Custom (1615 sq. ft.)

Deluxe (1767 sq. ft.)

Alcove (1800 sq. ft.)

Den Deluxe (2005 sq. ft.)

Homes

Learn more about our house options.

Custom One Bedroom Homes:

900-1099 sq. ft.

1100+ sq. ft.

Custom Two Bedroom Homes

Custom Two Bedroom Homes:

1200-1399 sq. ft.

1400-1599 sq. ft.

1800-1999 sq. ft.

2000-2199 sq. ft.

2200 + sq. ft.

Courtyard Homes

Courtyard Homes:

1 BR (1060 sq. ft.)

2 BR (1187 sq. ft.)

Patio Homes

Patio Homes:

2 BR (1326 sq. ft.)

Off-Campus Residency

Advantage Program

Applicant Financial Statement

Information provided is strictly confidential. All assets listed are available to provide financial support for residency.

Assets:

Stocks and Bonds (Market Value)

Stocks and Bonds (Annual Income)

Mutual Funds (Market Value)

Mutual Funds (Annual Income)

Certificates of Deposit (Market Value)

Certificates of Deposit (Annual Income)

Cash ie. Checking, Savings, Money Market (Market Value)

Cash ie. Checking, Savings, Money Market (Annual Income)

Trust (Market Value)

Trust (Annual Income)

IRA (Market Value)

IRA (Annual Income)

Real Estate — Home (market value less debt) (Market Value)

Real Estate — Home (market value less debt) (Annual Income)

Real Estate — Home Address

Real Estate — Other (market value less debt) (market value less debt) (Market Value)

Real Estate — Other (market value less debt) (market value less debt) (Annual Income)

Real Estate — Other Address

Other

Other (Market Value)

Other (Annual Income)

Total Assets & Income from Assets (Market Value)

Total Assets & Income from Assets (Annual Income)

Income:

Social Security — Person 1 (Monthly Income)

Social Security — Person 1 (Annual Income)

Social Security — Person 2 (Monthly Income)

Social Security — Person 2 (Annual Income)

Pension #1 Source

Pension #1 (Monthly Income)

Pension #1 (Annual Income)

Pension #2 Source

Pension #2 (Monthly Income)

Pension #2 (Annual Income)

Annuity Provider

Please include any benefit details or special terms.

Annuity (Monthly Income)

Annuity (Annual Income)

Will or Trust Administrator

Will or Trust (Monthly Income)

Will or Trust (Annual Income)

Rent Source

Rent (Monthly Income)

Rent (Annual Income)

Total Monthly Income

Total Annual Income

Does pension provide surviving spouse benefit? Cost of living increases? If so, at what percentages?

Does anyone owe you? If yes, give details on amounts, terms, repayment schedule, nterest rate, etc.

Do you owe any debts or have any judgments or claims pending against you? If yes, please explain:

Have you sold or transferred any real estate in the past five years? If yes, please explain:

If your assets and income are not expected to be sufficient to pay the Entrance Fee, Monthly or Daily Fee and personal expenses at Arbor Acres, indicate how you expect the difference between income and expenses to be met.

Other comments/remarks:

Consent*

I understand that my name will be placed on a waiting list for the type of accommodation I have requested, provided my application is accepted by Arbor Acres. I understand this application is a preliminary step in the consideration of my acceptance as a resident and does not make a commitment on either my part or that of Arbor Acres.

I understand that it is Arbor Acres’ policy to conduct a sex offender screening to protect the safety of its residents, employees, and guests, as part of its admissions review process. I also understand that should that screening show that I am identified as a sex offender, Arbor Acres will deny my admission on that basis. My signature below is my consent to this screening.

I declare the answers provided, and consents agreed to, in this document to be true and I authorize Arbor Acres to verify with any person or agency the accuracy of the information provided on this form and its accompanying documentation. The provision of false or intentionally misleading information can impact my admission to Arbor Acres.

I understand the $1000 per person fee will become a credit towards my entrance fee if I do move to Arbor Acres. I understand the $1000 per person fee is non-refundable if I do not move to Arbor Acres.

Please mail fee to:
Arbor Acres United Methodist Retirement Community, Inc.
1240 Arbor Road, Winston-Salem, NC 27104
(336) 724-7921

I Consent.

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