UnBiased PCH(Personal Care Home) Housing_Waitlist_Application

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Housing Waitlist Program Application Form

Section 1: Personal Information

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1 Full Name Required

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2 Date of Birth Required

Date

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3 Phone Number Required

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4 Email Address Optional

example@example.com

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Section 2: Current Housing Situation

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5 Current Address Required

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6. Do You Currently Have Housing Assistance? (Required):4

YESNO

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If Yes please specify

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7.Reason for Applying for Housing Assistance Optional

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Section 3: Household Information 8. Household Size (Required):

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Monthly Household Income AmountPlease enter amount below

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10 Do You Have Any Special Housing Needs or Accommodations Optional

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Name of Employer/Income Provider(If Applicable)

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Job Title(If Applicable)

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Employer Phone Number(If Applicable

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Are You Open to Shared Living Arrangements? (Required)

Yes

No

Maybe,depending on the arrangement

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Do You Have Any Disabilities or Medical Conditions That May Require Specific Housing Accommodations? (Optional)

Yes

No

Other

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Do You Require Accessibility Features? (Optional) (For example, wheelchair ramps, grab bars, etc.)

Yes

No

Other

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Do You Have a Criminal Record? (Optional) (This information will not automatically disqualify you but helps us in placement decisions.)

Yes

No

Other

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Upload Valid Drivers License

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Upload Proof of Income or other supporting documents

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Acknowledgment (Required): []I certify that the information provided is true and accurate to the best of my knowledge.

YESNO

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Digital Signature Please sign here!

Clear