Room Rental Application Form
By typing your initials and checking the boxes below, you agree to our non-negotiable rules.
Are you applying for a private room or shared room?
Please Select
Private Room
Shared Room
What date would you like to move in?
-
Month
-
Day
Year
Date
Applicant 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.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you smoke?
Yes
No
Are you a Convicted Felon?
Yes
No
Have you ever been Evicted?
Yes
No
Do you have pets?
Yes
No
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.
Your Needs
Do you need additional services to come into the home? i.e. home health, personal support, physical therapy, supported living coach.
Please Select
Yes
No
If yes, specify what kind of care and how many times a week you need support
Do you take prescription medicication
Please Select
Yes
No
If so, do you need assistance with medication administration?
Please state below any additional needs you may have
Current landlord Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Start Date
-
Month
-
Day
Year
Date
Monthly Rent
Previous Landlord's Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Monthly Rent
$
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Employment/Income
Company Name (i.e. workplace, social security etc.)
Starting Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor/Case managers 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 (non family member)
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Notes
Proof of Employment/Income
Employment/Income Proof
Browse Files
Drag and drop files here
Choose a file
Employment Letter, Two Months Pay Stubs, SSI letter, SSDI letter, etc.
Cancel
of
Move-in Cost/ Payment Method
Are you able to pay four weeks or One Month's rent upfront?
Yes
No
Other
Are you able to pay a one-time, non-refundable, move-in/move-out/key set-up fee?
Yes
No
Other
What Payment Method do you plan to use?
Cash
Paypal
Other
Will you be able to stay for at least 6 months?
Yes
No
Other
How long would you like to stay with us? (3 months, 9 months, 12 months, or more?)
Signature
Submit
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