NOTICE: Please complete, print and mail or Fax.

Admissions Coordinator
Founders Pavilion, Inc.
205 East First Street
Corning, NY 14830
Phone: 607-654-2408
Fax: 607-654-2449

Your Name:

Your Email:

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Applicant Name: (First, Middle, Last. Maiden):
Where is the applicant presently?
Home Address:
County of Residence:
Phone Number:
Sex:
Applicant Social Security Number:
Birth Date:
Place of Birth
Spouse's name:
Marital Status:	Married   Widowed   Divorced   Single
Physician:
Religion:
Advanced Directives:
Proxy? yes no DNR? yes no Living Will? yes no
(A Copy will be requested at time of admission)
Previous Occupation:
Applicant/Spouse a Veteran:	yes no
Funeral Home and Phone Number:
Prepaid Itemized Burial:	yes no
Person(s) to Notify in Emergency:
Name of First Individual:
Relationship:
Address:
Home Phone:
Work Phone:
Cell Phone:
Name of Second Individual:
Relationship:
Address:
Home Phone:
Work Phone:
Cell Phone:
Secure Financial Information to be provided at Admission, but please fill out the following
Person Managing Applicant's Funds:
Name:
Relationship:
Power of Attorney:	yes no
Address:
Home Phone:
Work Phone:
Please enter the below text Submitted via Normal Email (not secure email)