West Cook YMCA Resident Application

Resident Applicant Information
Resident Applicant Name *

First Name Last Name
Resident Applicant Date of Birth *

Month Day Year
Date
Resident Applicant Social Security Number. This is a secure form and all submissions will be encryped. *
Resident Applicant Phone Number *
Please enter a valid phone number.
Resident Applicant Email *
example@example.com
Resident Applicant Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Own or Rent *

Own Rent
Monthly payment or rent *
How long have you lived at this address? *
Resident Applicant Previous Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Own or Rent? *

Own Rent
Monthly payment or rent *

General Information
Have you ever been served an eviction notice? *

Yes No
If so, when? *

Month Day Year
Date
Have you ever been convicted of or pleased no contest to a felony or misdemeanor? *

Yes No
If yes, please give date, offense, and outcome. *
Do you have any additional income? If so, please explain source of income and amount. *
When would you be able to move in after January 1, 2022? *

Month Day Year
Date

Authorization to Obtain a Criminal Background Check

By signing and submitting this resident application, you hereby authorize the West Cook YMCA Business Office to obtain a criminal background report on myself for the purpose evaluating my eligibility for resident and annually if accepted as a resident of West Cook YMCA.

I am applying to be accepted as a resident of the West Cook YMCA. If accepted as a tenant, I agree to abide by the rules of the YMCA. I certify that all statements made on this application are true, correct, and complete and that all income has been listed.
Resident Applicant Signature

Clear
Date of Signature *

Month Day Year
Date
Should be Empty:

Resident Applicant Information