Room Rental Application Form
Oak Bluff Homes
Applicant Information
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.
Health Information
Do you smoke?
Yes
No
Have been diagnosed with any mental health conditions?
Yes
No
If yes, please list all your diagnosed mental health conditions.
Are you capable of taking medications on your own?
Yes
No
Background Information
Have you been to jail or prison in the last 5 years?
*
Yes
No
If yes, a) what year and b) what was the crime?
Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Financial Information
Are you able to pay first month rent up front (upon move in) ?
Yes
No
Other
How do you plan to pay rent? (Please select all that apply)
Government funding (e.g. SSI of SSDI)
Assistance from a Non-Profit Organization
Money from your job
Other (Please specify)
What Payment Method do you plan to use?
Cash
Zelle
Venmo App
Square Cash App
Paypal
Google Pay
Other
Will you be able to stay for at least 6 months?
Yes
No
Housing Needs
What type of housing are you in need of? (Please select one)
Permanent Housing
Transitional Housing
Emergency Shelter
What is your desired move in date?
-
Month
-
Day
Year
Date
Case Manager
Do you have a Case Manager?
Yes
No
If yes, please provide their Name, Organization, and contact information.
Submit
Should be Empty: