Levy Gardens | Application for Tenancy

Personal Information

Applicant's Name
Address
City
State
Zip
Phone
Date of Birth
Age
Present Housing (apartment, private home, condo, etc.)
Place of Birth
Synagogue/Religious Affiliation
I have lived in Youngstown since:
My last occupation was:

Marital Status

Marital Status:
 Single
 Married
 Widowed
 Divorced
Date of Divorce or Spouse's Death
Spouse's Name
Spouse's Age
Spouse's Phone Number
Spouse Address
Spouse's Employment

Insurance Information

The following information is very important and must be thorough and accurate.

Social Security Number
Medicare Hospital Insurance - Part A & Part B
 Yes
 No
Medicare Number
Medicare Supplemental Insurance
 Yes
 No
Supplemental Carrier
Group Number
Service
Address of Plan
City, State Zip
Other Hospitalization Plan
Group Number | Other Hospitalization
Service | Other Hospitalization
Address of Plan
City, State Zip

Application Fee

A non-refundable $100/per person application fee must accompany this application.


Billing Information

Deposit
 $100  
First Name
Last Name
Email
Address
City
State
Zip
Phone
Card Type
Card Owners Name
Card Number
Expiration Date
Total Payment
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