• Please read the following carefully before completing this form:

    This is not a rental application. This form collects basic information about you and your move-in needs. There's no fees for this form. The purpose of this form is to determine whether you will get approved or not. So please fill out the form truthfully. This will save time and protential candidates application that will get approved or not. A thorough background check will be performed once the actual application are submitted.

     

  • Date of Birth*
     - -
  • Move-In Date *
     - -
  • Do you have a steady source of income?*
  • Do you have funds available for the first month's rent?*
  • If you do not have funds on your own, will you have available help willing to provide for you?*
  • Do you receive Food Stamps/EBT (SNAP benefits)?*
  • Are you able to live independently without daily assistance?*
  • Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc?*
  • Do you have any physical disabilities or mobility concerns?*
  • Are you currently taking any prescribed medications?*
  • Do you have any difficulty accessing your medications (cost, transportation, insurance, etc)?*
  • Are you currently employed?*
  • Have you ever been evicted from a previous housing program?*
  • Have you ever been convicted of a felony?*
  • Was it a violent offense or non-violent offence?*
  • Are you a registered sex offender?*
  • Are you willing to follow house rules (no drugs, no unapproved guests, quiet hours, cleanliness?*
  • Do you smoke?*
  • Do you have any pets?*
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  • Should be Empty: