Shared Living Waiting List Application

Shared Living Wait List Application

Membership Application
Provide Your Member Information
First and Last Name:*
Date of Birth:*
Phone Number*

Area CodePhone Number
Email Address*
example@example.com
How did you hear about us*
Where are you currently living?:*
Why are you looking for housing right now?:*
Length Of Stay:*
Selections are based on preference availability
Payment / Income Source:*
Members must have and provide proof of income!
Are you currently employed?*

YesNo
Name of Employer and Hours of employment if applicable:*
If not employed put: NONE
Are you receiving assistance from an organization, hospital, or caseworker?*

YesNo
Name of organization/ caseworker name and contact information, if applicable:*
If not applicable put: NONE
Do you have any pets?*

YesNo
Do you smoke?*

YesNo
Do you have any history of violence or unsafe behavior?*

YesNo
Do you have a vehicle?*

YesNo
Shared Living Membership Location Preference:*
Selections are based on preference availability
Membership Community Preference*
Shared Living Preference:*
Housing is shared among members- Private Room Membership & Family Membership options are offered at an increased rate.

Emergency Contact Name and Number*

	First and Last Name	Phone Number	Relationship
1
2

Please provide 3 References Name and Number*

Membership Acknowledgement!

– I understand that this application for membership with Successful Solutions Shared Living is a membership agreement, and not a lease or tenancy. If approved, I will become a paid member of this shared housing community, holding a license to occupy, which can be revoked if the rules are not followed.

– I understand all membership plans are month-to-month!

– I understand that no deposit is required.

– I understand Membership Minimum Age 21

– I understand the membership properties do not allow pets

– I understand that the membership residential properties will allow smoking of tobacco products, and medical marijuana only in designated areas outside of the home, and that there is absolutely "NO SMOKING ALLOWED INSIDE" the residential properties.
Signature*

Clear
Date*

MonthDayYear
Date
ALL DONE! PLEASE SUBMIT!

Our office will contact you within 1-2 business days.
Should be Empty:

Shared Living Wait List Application