Making Pelican Landing Your Home Starts Here Reserve your apartment today!Memory Care Space is Limited: Upon completion of this non-binding form, our staff will reach out to answer your additional questions. Prospective Resident Application If you would like more information about our facility please fill out this form.Resident Name:* First Last Address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:*Email* How did you learn about Pelican Landing?Referred by?Contact Person First Last RelationshipContact Person Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person PhoneContact Person Email Please Identify Your Interest – Information will be sent to you.Living Options - Check One* Assisted Living Memory Care 1 Bedroom 2 Bedrooms Memory Care SuitePlease Identify Important Amenities/Services* Housekeeping or Laundry Restaurant Prepared Meals Nursing Services Pet Friendly Community Heated Garage Social Activities 24 hour Emergency Response System Storage Units Fitness Center Location of ApartmentFinancial Information:* I have long term care insurance which may help pay for Assisted Living. I will pay for Assisted Living privately. I may not be able to pay privately and I may need Government Assistance.Please select which one applies to you.CAPTCHAΔ
