Resident Application
1. Personal Information
Full Name:
Date of Birth:
-
Month
-
Day
Year
Date
Gender:
Phone Number:
Email Address:
example@example.com
Current Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City / State / Zip:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number:
Driver's License Number:
2. Household Information
Are you currently living alone or with others?
Do you have any children?
Yes
No
If yes, age(s):
Are you a veteran?
Yes
No
3. Housing Needs
Why are you seeking housing at Affirm Community Homes?
When would you be available to move in?
Do you have any special accommodations or needs?
Yes
No
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4. Income Information
(Required for program eligibility)
Primary Income Source:
Employment
SSI
SSDI
VA
Other
Monthly Income: $
Employer / Agency Name (if applicable):
Position / Role:
5. References
Personal or Professional Reference (not family):
Name:
Emergency Contact:
Name:
6. Lifestyle & Program Suitability
Do you smoke?
Yes
No
Do you use alcohol or recreational drugs?
Yes
No
Have you ever been convicted of a violent crime?
Yes
No
Are you able to live independently in a shared-living environment?
Yes
No
Please briefly describe why you would be a good fit for Maison de Paix - House of Peace:
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Background Check Authorization & Consent Form
Consent to Background Check
I,
(Participant), authorize Affirm Community Homes – Maison de Paix ("Program") to conduct a background check to evaluate my eligibility for participation in the independent living program.
I understand that this background check may include, but is not limited to, the following:
Criminal Records Search (local, state, federal)
Public Court Records Search (civil or criminal)
Sex Offender Registry Search
Verification of Employment / Income
Other public records as deemed necessary by the Program
I understand that the information obtained will be used solely for program eligibility and compliance with program rules.
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Authorization & Release
I authorize the Program and its representatives to gather, verify, and use the above information. I release all parties involved in providing information or reports from liability arising from the background check process.
I understand that:
I am a program participant, not a tenant or resident.
The Program reserves the right to deny participation or terminate participation immediately based on results of this background check or any violation of program rules.
This authorization is valid for the duration of my participation in the program.
Participant Acknowledgment
I have read and understand this Background Check Authorization Form. I voluntarily consent to the background check described above.
Participant Signature:
Date:
-
Month
-
Day
Year
Date
Program Representative Verification
I confirm that the participant has completed this form and has provided true information to the best of their knowledge.
Name / Title:
Signature:
Date:
-
Month
-
Day
Year
Date
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