Authorized representative name and title *

Work email *

Mobile or direct phone *

Residence name *

Legal business name *

Trade name if different (optional)

Residence street address *

City *

State *

ZIP *

Date this residence first opened to residents (or expected opening date) *

Website (optional)

Housing type *

Independent or shared living

Residential or boarding home

Assisted living

Other

County this residence serves *

Residents accepted *

Age groups accepted *

Under 55

55–61

62–64

65 or older

Room types available *

Minimum monthly rate *

$

Monthly rates by room type and what is included *

Accepted payment sources (select all that apply) *

Levels of help with daily activities offered *

Mobility levels supported *

Secured memory care offered *

Other daily support needs this residence can meet *

Smoking permitted *

Couples or spouses accommodated

Dietary accommodations

Accessibility features and functional accommodations (optional)

Other admission criteria or circumstances requiring review (optional)

Current availability *

Current openings by room type *

Date availability was last confirmed *

Person who can confirm availability and accept an offer *

Preferred referral method (select all that apply) *

Best referral email *

Best referral phone *

Hours you can respond to referral offers *

Licensing status *

Licensed

Not required to be licensed

License type, number, and issuing agency — or the legal basis for the exemption *

Documents (upload now or send before approval)

Please confirm each statement below (check all four) *

Authorized to submit; information accurate and complete

Holds every required license or is exempt

Admission practices comply with fair housing laws

Understands review, signed agreement and activation are required

I’m interested in the optional Vendor Access Add-On ($50 per enrolled location per month). I understand it is separate from housing referrals and requires a signed Add-On agreement.

Yes

I agree to receive text messages from Dignity Living Solutions about referral offers and my application at the phone numbers above. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help. Consent is not required to apply.

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