Housing Provider Pre-Application Requirements*
*
I am a current resident of Los Angeles County
I have a private bedroom available for rent
I have never been convicted of a crime
Name*
*
Email*
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Why have you decided to share your home?*
*
Examples: extra income, companionship, help with household tasks
What is your current monthly income?
*
How long have you resided in California?
I prefer*
*
Rent Only
Rent + Living Support Services
If you prefer Living Support Services, which do you need?
Housekeeping
Shopping
Cooking
Laundry
Transportation
Companionship
If applicable, how many hours per week do you need assistance?
1 to 5
5 to 10
10 to 15
What rent amount will you charge? (per month)*
*
Have you ever shared housing with a non-family member/spouse?
Yes
No
Are you currently employed?*
*
Are you offering a private bathroom?*
*
Yes
No
Are there stairs in the home?*
*
Yes
No
Is the room for rent furnished?*
*
Yes
No
If furnished, please describe
Examples: Bed frame with mattress included, desk, lamp
What will your guest have access to?*
*
Washer
Dryer
Access to Kitchen
Additional Storage
Driveway
Street Parking
Garage
None of the Above
Anything else you would like to mention about your home?
Describe your typical daily schedule
On a scale of 1 to 10, how do you rate your housekeeping standards?
1
2
3
4
5
6
7
8
9
10
How often do you have company?
Never
Sometimes
Always
How often do you have overnight company?
Never
Sometimes
Always
Are you fluent in any language other than English?
Examples: Spanish, Mandarin, Armenian
Do you have pets?
If yes, what kind?
Do you smoke?
Do you drink alcohol?
Do you have any medical conditions that affect your day-to-day life?
*
Do you have a special diet that a roommate would need to be aware of?
Examples: Kosher, vegetarian/vegan, salt-free
Rental Duration Preference*
*
Month-to-Month
3 Months
6 Months
1 Year
1 Year or longer
On a scale of 1 to 10, how clean do you prefer your roommate to be?
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 5, how often do you want to interact with your roommate?
1
2
3
4
5
How often is it OK for your roommate to have company?
Never
Sometimes
Always
Pets Preference
Don't Mind
No Pets
Drinking Preference
Don't Mind
No Drinking
Smoking Preference
Don't Mind
No Smoking
COVID-19 Roommate Expectations
Same as mine
Similar but willing to negotiate differences
No expectations
Do you have a disability?
*
Yes
No
Veteran Status - Have you served in the United States Military?
*
Yes
No
What race/ethnicity best describes you?
*
A - Asian American/Pacific Islander/Asian
B - Black/African American/African
C - Hispanic/Latino/Latina/Latinx
D - Native American/American Indian/Indigenous
E - White/Caucasian/European
F - Multi-racial/Multi-ethnic (Two or More)
G - Unknown/Decline to State
What is your current gender identity? (Please select all that apply)
*
Woman
Man
Non-binary
Genderqueer
Prefer not to state
If gender identity is not listed above, please specify:
Emergency Contact Name*
*
Emergency Contact Relation*
*
Examples: Son, daughter, cousin, close friend
Emergency Contact Phone Number*
*
How did you hear about our Shared Housing program?*
*
Internet search
Referral/word of mouth
Social media
News source
Other
If Referral, please list organization or individual
If Other, please explain
You have a right to obtain a copy of any consumer credit report or investigative consumer report obtained by ALA by checking the box provided below.
I request a copy of any consumer credit report or investigative consumer report obtained by ALA
Date of Birth
-
Month
-
Day
Year
Date
Driver License # / State
SSN*
*
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