Empower Path Homes - Resident Application Form

Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Emergency Contact Name

Emergency Contact Phone #

YesNoOther

YesNo

Are you currently working with a case manager, PO, or Housing agency? Kindly provide their Name, Contact # & Agency:

YesNo

Do you have any criminal background? If yes, please explain. (this will not disqualify you)

SharedPrivate

Move-In Date?

Date

Resident Agreement Summary

By signing this form, I understand that Empower Path Homes:

Is an independent living, not a medical or assisted care facility.
Offers housing, with shared and private room options.
Does not provide medication management, therapy, or custodial services.
Reserves the right to remove residents for violating house rules or causing harm to others.
Requires payment of monthly rent on the 1st of each month, no exceptions.,
Runs independent background check on all new tenants at clients’ cost.

Signature

Today's date

Date