Residency Questionnaire
DEXTrust Industries
Residency Questionnaire
Step 1 of 5
20%
Name
*
Thank-you for your interest in the Veterans Villages of New England Residency Initiative. Our Residency placement team would ask that you provide us feedback to understand how we can best serve your needs. Please provide the requested information to be registered for our Residency program.
First
Last
Email
Phone
Your Current Zip Code
Which Service Era where you a part ?
World War I
World War II
Korean Conflict
Vietnam Era
Persian Gulf War
Active
Has Any of the following impacted your residency decisions ?
2019 Novel Coronavirus
Housing Cost
Lack of Available Housing
Has Any of the following impacted your residency decisions ?
2019 Novel Coronavirus
Housing Cost
Lack of Available Housing
Will your location require support of any physical challenge ?
Yes
No
What Type of residency are you Interested in ?
Personal Residence
Independent Living
Home Care
Assisted Living
Are you a Gold Star Family ?
Yes
No
How many persons will be living with you including yourself ?
Myself Only
Myself plus 1 other person
Myself plus 2 other person
Myself plus 3 other person
How many bedrooms will you need ?
Single Occupancy
Double Occupancy
Triple Occupancy
Quad Occupancy
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