Room Rental Placement And Screening Services Intake Form

1
Date* This field is required.
Date
Month
Day
Year
2
Referrer's Name
First Name
Last Name
3
Referrer's Phone Number
Please enter a valid phone number.
4
Referrer's Email Address
example@example.com
5
How Did You Hear About This Service?* This field is required.
6
Housing Provider's Full Name* This field is required.
First Name
Last Name
7
Housing Provider's Phone Number* This field is required.
Please enter a valid phone number.
8
Housing Provider's Email Address* This field is required.
example@example.com
9
Please Upload A Clear Photo Of The Housing Provider's State ID* This field is required.
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10
Address of the property with the room rental(s)* This field is required.
11
Type Of Property* This field is required.
House
Townhome
Mobile Home
Apartment with written sublease approval from the property owner or management company AND from the primary leaseholder
Other
Other
12
This property is:* This field is required.
Owned by you
A home where the owner has authorized room rentals or occupy/room occupancy agreements
Being rented by you and you have permission to sublease the rental
Being rented by you and roommates are permitted
Other
13
This Shared Household Is:* This field is required.Check all that apply
Co-Ed
For Women
For Men
For Moms With Children
For Re-entry Residents
For Veterans
An Independent Living Shared Household
14
Name Of the room renting business, if applicable:Such as the name of an Independent Living Rental Business
15
Who Are Your Preferred Residents (examples: males, females, veterans, seniors, adults, students, nursing students, traveling nurses, flight attendants, working professionals, people on government assistance, social security recipients, etc.)
Huge
Large
Normal
Small
Ok
Ok
16
Business Website, if applicable
17
Business Phone Number, if applicable
Please enter a valid phone number.
18
Business Email Address, if applicable
example@example.com
19
Private Room Monthly Rate
20
Shared Room Monthly Rate
21
How many private rooms are available for rent?* This field is required.
22
How many shared bedrooms are available for rent?* This field is required.
23
Is there a security deposit? If so, how much is the security deposit?* This field is required.
24
Are pets allowed?* This field is required.
25
Is smoking allowed?* This field is required.
26
Are guests allowed?* This field is required.
27
Is parking available at the property?* This field is required.
28
Is public transportation available near the household?* This field is required.
Please Select
Please Select
Yes
No
Should be Empty: