at St. Andrew's Place assisted living community

Contact Us

Application
Directions
Inquiry
Move In

This is a printable form. Please fill it out then print the page and send it to our offices.

Unit Application: Desired Move-In Date: Unit #: Full Name: Address: City/State: Age: Former Occupation: Marital Status: Financial Information: S.S.#: Birth Date: Phone: 2nd Occupant’s Name:

Financial Information: Average Monthly Income: Assets to Draw Upon: Other Resources: Medicare: Medicaid: Other:

I understand that my reservation fee of $100.00 is not refundable unless it is determined by ST. ANDREW’S PLACE that I do not qualify for tenancy or if within one (1) year of application a unit does not become available. This fee is waived for Medicaid eligible individuals.

CONTACT FOR FUTHER INFORMATION: Name: Address: Home Phone: Work Phone: Relationship: City/State: Applicant’s Signature: Date:

Please print this page and send the completed applications to:

St. Andrew’s Place
520 E. Park Ave.
Port Angeles, WA 98362
standrew@olypen.com

For office use only: Date application received ______/________/_______

Home About Our Community Contact Us Photo Gallery
Contact Us Application Directions Inquiry Move In	This is a printable form. Please fill it out then print the page and send it to our offices. Unit Application: Desired Move-In Date: Unit #: Full Name: Address: City/State: Age: Former Occupation: Marital Status: Financial Information: S.S.#: Birth Date: Phone: 2nd Occupant’s Name: Financial Information: Average Monthly Income: Assets to Draw Upon: Other Resources: Medicare: Medicaid: Other: I understand that my reservation fee of $100.00 is not refundable unless it is determined by ST. ANDREW’S PLACE that I do not qualify for tenancy or if within one (1) year of application a unit does not become available. This fee is waived for Medicaid eligible individuals. CONTACT FOR FUTHER INFORMATION: Name: Address: Home Phone: Work Phone: Relationship: City/State: Applicant’s Signature: Date: Please print this page and send the completed applications to: St. Andrew’s Place 520 E. Park Ave. Port Angeles, WA 98362 standrew@olypen.com For office use only: Date application received ______/________/_______
520 East Park Avenue, Port Angeles, WA 98362 - Ph. (360) 417-3418 - Fax (360) 457-3468