(Community Name)
Senior Roommate Sharing
Program
(Community Name)
Senior Roommate Sharing
Program

Are you tired of living alone and would like to split the rent? If you answered YES then let us help you find a roommate by filling out the questionnaire below.
Are you tired of living alone and would like to split the rent? If you answered YES then let us help you find a roommate by filling out the questionnaire below.

Name: | Phone: | AGE: | Tentative Move-In Date: | How many roommates are you willing to have? | Do you have a visiting nurse? * Yes * No | I WOULD PREFER MY ROOMMATE TO BE : * FEMALE * MALE * DOES NOT MATTER | I am currently employed and work: * Night Shift * Day Shift * Different shifts | SMOKING: * I smoke, but will not smoke in the apt. * I do not smoke and would not want a roommate that smokes. * I do not smoke but I do not mind that a roommate smoke outside. | My hobbies are?1.2.3. | ALCOHOL: * I am a social drinker. * I have a drink once a day. * I do not drink. | What type of music do you like?1.2.3. | PETS: * I do not have a pet * I have a pet * I do not want to live with someone that owns a pet * I don’t mind a roommate with a pet. | VISITORS: * I have a lot of visitors * I seldom have visitors | CLEANLINESS: * I am a neat freak * I clean once in a while * I do not like cleaning | Personality: * I am a social butterfly. * I like to stay to myself. * I am social but at times like to be left alone | | |