Housing Application
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Tenant Information
Full Name
First Name
Last Name
Gender
Female
Male
Other
E-mail
example@example.com
Phone Number
Private or Shared Room
Private ($975)
Shared ($720)
How Do You Plan To Pay?
SSI/SSDI
Retirement
Employed
Organization Funding
Present Employment
Employer
Occupation
Current salary range
Proof of Income
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Currently taking any medications
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No
Do you Drink Alcohol?
Yes
No
Do you Smoke?
Yes
No
Are you currently on Probation of Parole?(Your answer to this questions does not disqualify you from our program & services)
Yes
No
Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)
Yes
No
Next of Kin\Emergency Contact
Full Name
First Name
Last Name
Relationship
Phone Number
E-mail
example@example.com
Date
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Month
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Day
Year
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