Application For Admission To The New York Armenian Home Page 4
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10NEW YORK ARMENIAN HOME
TH
137-31 45
Avenue, Flushing, NY 11355
Tel: #718-461-1504 Fax #718-461-3079
APPLICATION FOR RESIDENCE
APPLICANT
________________________________________________________________________________
Surname
First Name
Middle Name
ADDRESS:___________________________________________________________________________
_________________________________________
COUNTY________________
Date of Birth:_________________________
SOCIAL SECURITY
#___________________________
Place of Birth:_________________________________________________________________________
City
State or Country
Father’s Full Name
Mother’s Maiden Name
___________________________
__________________________
Mother’s Occupation
_______________ Birthplace _______________Death Date _________________________
Father’s Occupation
_______________ Birthplace _______________ Death Date ________________________
Year of Entry into U.S
. ______________________
Sex:
( ) Female
( ) Male
Race:
Age: ( at last birthday ) ______________________
Citizenship Status:
( ) Native
( ) No data
( ) Naturalized
( ) Other (specify
)_______________________
( ) Alien
______________________________________
Occupation
: ________________________________
Religion
( ) Protestant
( ) No data
( ) Roman Catholic
( ) Other (specify)________________________
( ) Apostolic
Name and Address of Pastor or Priest:
__________________________________________________________
____________________________________________________________________________________________
If Apostolic, show which Parish Known best by the Priest:
________________________________________
____________________________________________________________________________________________
Marital Status:
( ) Single
( ) Divorced
( ) Separated
( ) Married
( ) Widowed
( ) No data
( ) Other
_____________________________
Maiden Name of Wife
________________________________________________________________________
Name of Last Known Spouse _____________________________________________________________
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