Residential Information Form

Resident Name: __________________________________ Unit Number: ________________

THE IMPERIAL PLAZA

RESIDENTIAL INFORMATION FORM

PLEASE PRINT OR TYPE LEGIBLY, PLEASE FILL IN ALL INFORMATION.

OWNER NAME: ___________________________________ AGENT'S NAME (IF ANY): _________________

OWNER PHONE (H)________________(C)______________ AGENT'S PHONE: _______________________

NAMES OF ALL OCCUPANTS:

1.________________________________ UNIT PHONE #:_______________________

2.________________________________ WORK PHONE #:_______________________

3.________________________________ CELL PHONE#(1):______________________

4.________________________________ CELL PHONE#(2):______________________

CHILDREN:

NAME AGE M OR F

5.____________________ __________ ______________
6.____________________ __________ ______________

VEHICLES: (PLEASE LIST ADDITIONAL VEHICLES ON BACK OF THIS PAGE)

YEAR:_____MAKE:_____MODEL:_____COLOR:_____LICENSE PLATE #:__________

IN CASE OF EMERGENCY:

1ST EMERGENCY CONTACT NAME ________________________________________

PHONE NUMBERS(H)_________________(W)__________________(C)____________

2ND EMERGENCY CONTACT NAME ________________________________________

PHONE NUMBERS(H)__________________(W)________________(C)_____________

DOCTOR:______________________________________ PHONE #:_______________

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PERSONS REQUIRING SPECIAL ASSISTANCE IN THE EVENT OF AN EMERGENCY (AND THEIR CONDITION):

NAME:____________________________________________AGE:_____________________

CONDITION:________________________________________________________________

__________________________________________________________________________

NAME:_____________________________________________AGE:___________________

CONDITION:_______________________________________________________________

_________________________________________________________________________

ADDITIONAL CONTACT INFORMATION:

NAME:___________________________________ BUSINESS PHONE:_________________

CELL PHONE NUMBER:_______________________PAGER/OTHER:____________________

I, THE UNDERSIGNED, HEREBY AGREE THAT I HAVE RECEIVED A COPY OF THE HOUSE RULES FOR IMPERIAL PLAZA AND WILL ABIDE BY THESE RULES. ALSO, I ACKNOWLEDGE RESPONSIBILITY FOR COMPLIANCE ON PART OF ALL OF MY GUESTS AND THE OCCUPANTS RESIDING WITHIN THE APARTMENT.

SIGNATURE:________________________________ DATE:______________________

(ALL ADULT OCCUPANTS PLEASE SIGN ABOVE)

____________________________________________________________________________________________________________

EXTRA SPACE BELOW PROVIDED FOR ADDITIONAL INFORMATION IF NEEDED.

___________________________________________________________________________________________________________

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The Imperial Plaza