Residential Application

Please fill out application, print, then mail to :
Manager
Winifred Stuart Mankowski Homes
819 North Citrus Avenue, Azusa, CA 91702

Page: 123 4 5 6

Which branch Church or Society do you belong to?
Since (year joined)

Please list the last three Branch Churches or Societies of which you have been a member, year joined, and reason for change:
a)
b)
c)

Would you list the various capacities in which you have served the Church of Christ, Scientist over the years?

Do you intend to continue active Branch Church participation? Yes No

Please describe your general condition of health :

Do you have any physical disabilities or disorders? Yes No

If yes, please describe the nature of them :

Are you able to take care of normal living needs (marketing, cooking, housekeeping) without assistance ?
Yes No

If no, please state why:

It is assumed as a working Christian Scientist that you are free from the use of tobacco , drugs and intoxicants. Is this a correct assumption?
Yes No

Please print this page prior to proceeding. Click here for next page.