Housing Application Form
Divine Housing
Guest Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you a U.S. Citizen?
Yes
No
Are you a Veteran?
Yes
No
Do you have any mobility aids (walker, wheelchair, rollator, cane)?
Yes
No
Are you a Convicted Felon?
Yes
No
Do you smoke?
Yes
No
Are you able to make sound decisions independently?
Yes
No
Can you independently manage activities of daily living (bathing, grooming, toileting, eating, transferring)?
Yes
No
If No, please specify which activities of daily living requires assistance
Do you have any major medical conditions or known mental health diagnoses?
Yes
No
If Yes, please specify
Current Information
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Income Information
Income Source (select all that apply)
Social Security
Private Pay
Social Security Disability Insurance
Community Assistance / Voucher
Supplemental Security Income
Other
Total Monthly Income
Current Employment
Company Name
Start Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor Name
Title
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Salary $
Monthly
Reference - Social Worker
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Notes
Move-in Cost/ Payment Method
Are you able to pay every month on time?
Yes
No
Do you understand we offer a furnished shared living community with beds available for rent?
Yes
No
What Payment Method do you plan to use?
Cash
Zelle
Venmo App
Square Cash App
Paypal
Google Pay
Other
How long do you plan to stay?
Save
Submit
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