Application for admission

Surname: Given name: Maiden name: National registration number:

Marital status: single married widow(er) divorced living with partner

Residence: N°: Street: Postcode: Location: Telephone: Mobile : Email:

Name and address of my trusted person (personne de confiance:) Surname: Given name: N°: Street: Postcode: Location: Telephone: Mobile : Email:

Longterm care unsurance Requested: Yes No Date: Assessed: Yes No

This form is to be submitted or send to the Municipal Administration of Walferdange, B.P.1 à L-7201 WALFERDANGE Admission Requirements Those 65 years of age or older who meet one of the following residency requirements have priority for admission:

The applicant must have resided in one of the following municipalities for the two years prior to the submission of this application: Niederanven, Walferdange, Schuttrange, Contern, Sandweiler ou Betzdorf.

A direct descendant (daughter/son) must have resided in one of the following municipalities for the six years prior to the submission of this application: Niederanven, Walferdange, Schuttrange, Contern, Sandweiler ou Betzdorf.

I am registering with the municipality because I’ve lived there for more than two years before the date of submission.

I am registering with the municipality because one of my children has lived there for more than six years before the date of submission.

I wish to be contacted if a room becomes available.

I take the the initiative of personally informing you of my decision to become a resident of CIPA (CIPA telephone: 347270-1)

Dated

(signature)

This form is to be submitted or send to the Municipal Administration of Walferdange, B.P.1 à L-7201 WALFERDANGE Section reserved for the Municipal Administration

Application sent to the secretary of the supervisory committee on

to be verified to determine whether the municipality will request the application be placed on the priority list even if the residency requirements and age requirements are only met indirectly.

Signature and seal of the Municipal Administration

This form is to be submitted or send to the Municipal Administration of Walferdange, B.P.1 à L-7201 WALFERDANGE