LKNBH Short Form Questionnaire

Short form questionnaire

Please complete this form and please ensure all information is accurate to facilitate your placement.
Thank you for your interest in independent living. Completing this form places you on our waiting list. Providing complete and accurate information will help us determine suitable housing options for you. We will contact you by email or phone with updates. If you have questions, contact our office at (682)465-8996.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Residential Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please describe your previous experience with shared living environments.
Do you have a verifiable source of income?
Do you agree to abide by the shared living community rules?
What is your source of income?
How did you hear about us?
Digital Signature
Should be Empty:

Short form questionnaire