Application For Housing
Applicant Details:
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Last Four of Social
*
Current Address (if Any)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Emergency Contact (Name, Relationship, Phone):
Name
First Name
Last Name
Relationship
Please Select
Parent
Spouse
Friend
Other
Please enter a valid phone number.
Format: (000) 000-0000.
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Background Information
Are you a
*
Senior
Veteran
Reentry / Transitional
Do you have a criminal background?
*
Yes
No
If Yes Please Explain
Have you ever been evicted?
*
Yes
No
Do you have outstanding warrants?
*
Yes
No
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Health & Medical Information
If none type "none"
Current Medical Conditions:
*
Current Medications:
*
Allergies:
*
Mental Health History (if applicable):
*
Primary Care Provider:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
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Financial Information
Source of Income (check all that apply):
*
Employment
Disability
Social Security
VA Benefits
Other
If "other" Please Explain:
Monthly Income (approximate):
*
Do you receive SNAP (Food Stamps)?
*
Yes
No
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Program Participation
What are your personal goals while living at Comfort Living Homes?
*
What areas do you need the most support in?(check all that apply)
*
Job Placement / Employment Assistance
Resume Building / Mock Interviews
Food Assistance / SNAP Support
Social Security / VA / Disability BenefitsSupport
Transportation Assistance
ADL Support / Home Health
Other
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Consent & Acknowledgement
By signing below, I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that false information may result in the denial of my application. I also acknowledge that acceptance into Comfort Living Homes requires: A background check, consent to random drug testing, completion of an interview before approval and an agreement to follow all program rules and expectations.
Type a question
*
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