ELDERLY PERSONS’ HOUSING
Withdrawal of Application / Refusal of a Unit Form
Withdrawal of Application
From:
Refusal of a Unit
Boyne Towers, Carman
Regency House, Portage la Prairie
Rotary Park, Portage la Prairie
Crescent Lodge, Gladstone
Centennial Apartments, Gladstone
Date: _________________________
Time: _________________________
Name of Applicant(s): ______________________________________________________________________
_______________________________________________________________________
Name of Individual communicating the information (applicant(s) or alternate contact as identified in application):
_______________________________________________________________________________________
Method of Communication:
Telephone
E-Mail
Letter
In-Person
Mailing address of individual communicating the information (applicant(s) or alternate contact as identified in
application):
Mailing Address: ______________________________________________________________________________
Street /Box Number
City/Town
Province Postal Code
Signature of individual receiving information on behalf of Southern Health-Santé Sud.
Letter of confirmation sent
(mm/dd/yyyy)
Withdrawal of Application / Refusal of Unit Form
Signature
ORG.2110.PR.003.FORM.01
January 10, 2017
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