Tenant Screening Form
Full Name
First Name
Last Name
Personal Info
Date of Birth
-
Day
-
Month
Year
Previous Address
Enter a valid email address for communication.
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
Enter a valid email address for communication.
Are you a citizen of United States?
Yes
No
Have you been evicted before?
Yes
No
Are You a Felon?
Yes
No
Emergency Contact and Relationship
First Name
Last Name
Emergency Contact Phone number
Enter a valid phone number for communication.
Format: (000) 000-0000.
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Are you a sex offender?
Yes
No
Economic Status
Income & Benefits
Employment
Ssdi
Ssi
VA
Housing Voucher
Other Form of payment
Are you currently employed with an active income?
Yes
No
Job Title
Company & Company Number
Average Monthly Income
Income in USD.
Do you have a family member or someone else who is employed with an active income and will help you financially?
Yes
No
Full Name
First Name
Last Name
Phone Number
Enter a valid phone number for communication.
Format: (000) 000-0000.
Full Name
First Name
Last Name
Phone Number
Enter a valid phone number for communication.
Format: (000) 000-0000.
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Can you Preform daily activities?
Please Select
Yes
No
Bathing, dressing, cooking, cleaning
Can you manage your own meds?
Please Select
Yes
No
Can you maintain personal hygiene and room cleanliness?
Please Select
Yes
No
Can you prepare simple meals & share/clean kitchen responsibly?
Please Select
Yes
No
Can you safely ambulate (walk, transfer, w/out help)
Please Select
Yes
No
Can you follow house rules & live cooperatively?
Please Select
Yes
No
Can you support yourself with out medical supervision, skilled care or nursing support?
Please Select
Yes
No
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Lease Details
Expected Accommodation Duration
Duration in months.
Number of Visitors
Do you have any pets?
Are you a smoker?
Yes
No
Please briefly describe anything needed to know.
Please briefly explain your reason for leaving your current accommodation place.
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References
Full Name of Your Reference
First Name
Last Name
Relation
Family, friend, etc.
Phone Number of Your Reference
Enter a valid phone number for communication.
Format: (000) 000-0000.
Full Name of Your Reference
First Name
Last Name
Relation
Family, friend, etc.
Phone Number of Your Reference
Enter a valid phone number for communication.
Format: (000) 000-0000.
Full Name of Your Reference
First Name
Last Name
Relation
Family, friend, etc.
Phone Number of Your Reference
Enter a valid phone number for communication.
Format: (000) 000-0000.
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Appointment To View Property
Confirmation
Submit
Should be Empty: