Bright Gate Solutions – Housing Application & Questionnaire
Email
example@example.com
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Section 1: Personal Information
Full Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Email Address (if different from the email collected above)
Current Address (Street, City, State, ZIP)
Emergency Contact – Full Name
*
Emergency Contact – Relationship
Emergency Contact – Phone
*
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Section 2: Housing & Financial (Membership)
Which membership are you applying for?
*
Shared Room – $650/month (2 beds/room, all-inclusive)
Private Room – $850/month (all-inclusive)
Primary Income Source
*
SSI
SSDI
VA Benefits
Employment (W-2)
Self-Employment (1099)
Other Assistance (explain below)
Monthly Income (approximate)
*
Do you currently receive government assistance or third-party pay?
*
Yes
No
If yes, please explain (agency, case manager, etc.)
Earliest Move-In Date
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Month
-
Day
Year
Date
Preferred Location/Area (optional)
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Section 3: Lifestyle & Roommate Compatibility
Do you smoke?
*
Yes
No
Do you drink alcohol?
*
Yes
No
Do you have pets?
*
Yes
No
If yes, list type/breed/size
Do you prefer a quiet environment?
*
Yes
No
Preferred roommate type
*
Same gender
No preference
Other (specify below)
If 'Other', please specify roommate preference
Describe your daily routine
*
Morning person
Daytime schedule
Night owl
Any allergies or medical conditions we should be aware of?
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Section 4: Background
Are you currently employed?
*
Yes
No
If yes, where do you work? (employer name)
Are you currently in a transitional program? (re-entry, rehab, probation, etc.)
*
Yes
No
If yes, please explain
Have you ever been evicted?
*
Yes
No
If yes, please explain the circumstances (optional)
Do you have any criminal history?
*
Yes
No
Are you under probation/parole supervision?
*
Yes
No
Are you a registered sex offender?
*
Yes
No
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Section 5: Support Needs
Do you need assistance connecting with social services?
*
Yes
No
Do you require help with transportation?
*
Yes
No
Do you require help with food assistance?
*
Yes
No
Do you need case management support?
*
Yes
No
Anything else we should know to support your housing?
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Section 6: Membership Agreement & Policies
How Did You Hear About Bright Gate Solutions?
*
Facebook
Google
Other
I understand Bright Gate Solutions is a non-licensed shared living facility and I agree to follow all house rules.
*
I agree
I understand this is a membership program, not a lease/tenant agreement.
*
I agree
I agree that membership fees are due on the 1st or 3rd of the month (depending on my financial situation).
*
I agree
I understand that after the 5th of the month, a $25 late fee will be charged for every day late.
*
I agree
Type your full name as your electronic signature
*
Submit
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