Housing Application

Housing Application

We reserve the right to accept or decline applications in accordance with applicable laws and program criteria. Meeting the eligibility requirements does not guarantee acceptance. A criminal history, or lack thereof, does not automatically guarantee approval or denial. Each application is evaluated individually in accordance with applicable laws and program guidelines. Due to privacy protections, we will not show any rooms or homes prior to applicants scheduled tours or move in dates.
Program Criteria
For approval into the program, occupants MUST have a minimum of all of the following requirements :
- Have stable verifiable income (employment, SSI, SSDI, Veteran benefits)
- Have the ability to independently perform daily activities (bathing, grooming, eating, dressing, take prescription medication)
- Be comfortable sharing a living space with others
About You
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If Living in or frequently visiting a Shelter, please specify the name of the shelter.
Emergency Contact (Name and Phone #)
Caseworker Name and Phone # (if applicable)
Do you have any known allergies? If so, please specify. If no, please type: N/A.
Do you have any weapons? If so, please specify the type and quantity. If no, please type: N/A.
Do you consent to a background check? (Background checks are required for acceptance into the program.)
Do you have your own transportation?
Parents
Do you have children?
If yes, please specify how many children are in need of housing and their ages. (Allowed children ages: 12 months-17 years old) (Max: 2 children)
For parents with small children:
- You can pay the price of a private room (1 full size or queen size bed)
or
- Pay for multiple beds in a shared room (each room will have 2-3 beds)
For parents with small children (ages 1 years-17 years old), are you interested in joining the waitlist for the house exclusive to parents with small children?
Income Information
Income Type
If Other, please specify
If Employed, please specify the name of Company Name
Company Phone #
When did you begin working? (If you don't remember the exact date, please estimate)

MonthDayYear
Date
How often are you paid?
If Other, please specify
Income Verification Upload (paystubs, SSI/SSDI verification form, Veteran Benefit proof, etc.)

Cancelof
Criminal History
Have you ever been convicted of a crime or served time in prison?
If yes, please specify the crime and how long in prison
Mental Health
Are you able to perform basic daily duties such as bathing, dressing yourself, eating, cleaning up after yourself with no assistance?
Have you been diagnosed with any mental health/intellectual/developmental disabilities, disorders?
If yes, please specify
Do you take any prescribed mood stabilizing, modifying, or behavioral stabilizing/modifying medications? IF yes, please specify how often. If no, please type: NO.
Rental Information
Have you ever been evicted?
Are you interested in the Homeless Restoration Project? (where we provide you financial resources, career services, and continuing education services)
If yes, please specify which service you are interested in.
How long do you anticipate being in the program?
When are you in need of housing?

MonthDayYear
Date
Are you ok with coed housing with men and women?
Are you interested in a private bedroom or shared rooms?
If no private rooms are available, are you open to shared rooms?
Drug/Alcohol Use
Are you a smoker?
If other, please specify
Are you a drinker?
Referrals
Do you know of anyone else in need of housing? If so, please provide their Name, and phone #. if not, please write N/A.
References-Please provide at least 1 personal or professional reference contact info:
Signature
Today's Date:

MonthDayYear
Date

Admin Fee: $125 ($75 holding fee is Refundable if application is not accepted)

USDIncludes $50 background check and $75 holding fee. Holding fee guarantees your spot in an available room. If no rooms are available at that time, you will be placed on the priority waitlist for when one is available.

Payment Methods

Credit Card

Apple Pay

Google Pay

Should be Empty:

Housing Application

Program Criteria

About You

Parents

Income Information

Criminal History

Mental Health

Rental Information

Drug/Alcohol Use

Referrals

Admin Fee: $125 ($75 holding fee is Refundable if application is not accepted)*

Payment Methods

Admin Fee: $125 ($75 holding fee is Refundable if application is not accepted)