If you would like to receive more information about Pine valley
Retirement Community, please take a moment to fill out our
questionnaire. We will send you a packet of detailed information
about our community, and include you on our mailing list.

* Required fields are marked with red asterisk.

Name *

Address *

City *    State *    Zip *

Tel # ( ) - *
 Email Address *

YOUR INTERESTS/PRIORITIES:
Fishing
Continuing Education
Historic Sites
Healthcare/Fitness
Gardening
Athletic Events		 Civic Organizations &
        Volunteering
Arts & Crafts
Travel
Church

YOUR AGE RANGE:
55-65
66-75
76-85
86-90
91+

YOUR HOUSING PREFERENCE:
Assisted Living

Independent Living
1 BR Apartment
2 BR Apartment
1 BR Patio Home
2 BR Patio Home

HOW DID YOU HEAR ABOUT PINE VALLEY?
Mail-out
TV ad
Newspaper ad
Trade Show
Referral
 Other