Malaika Homes Waitlist Form
Please fill out the form below to verify your eligibility for shared housing.
Full Name
First Name
Last Name
Gender
Male
Female
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Anticipated Move in Date?
DD/MM/YYYY
Are you currently employed?
Yes
No
If yes, please provide the Name of your employer below.
Income Source
Wages
VA Benefits
Social Security
SSI/SSDI
TANF
Annuity
Other
Other
Do you have a Bank Account?
Yes
No
If Yes, Please Select
Please Select
Checking
Savings
Both
Account Balance Total
Who will pay your Rent?
Client Pays
Third Pary Payee
Have you ever been evicted from a previous residence?
Yes
No
If yes, Please provide details on your eviction history.
How did you hear about us
Website
Friend/family member
Newsletter
Organization/Other
If organization or other source, please fill in
Comments:
Submit
Should be Empty: