ROOMS FOR [RENT, VETS] FORM
Disclaimer: The information you provide on this form will be kept confidential. Submission of this form does not constitute an approval. Final approval is contingent upon verification of the information provided and meeting program guidelines. We provide shared and private rooms based on availability.
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Are you Male or Female?
*
Male
Female
Name of Sponsor (Company, Organization, Individual or NA)
Photo ID Upload
*
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PLEASE COMPLETE QUESTIONNAIRE
Are you looking for Private Room or Shared-Room?
*
Private Room
Shared Room
Who is Applying?
*
Military Veteran
Homeless Adult
Independent Seniors (55+)
Working Adult
Re-Entry Adults (62+)
Adult w/Fixed or Low Income
Travel Professional
College Student
Other
Please describe your interest or needs regarding group home services.
Are you currently homeless?
*
Yes
No
Do you have a violent criminal history?
*
Yes
No
Are you being released from an institution?
*
Yes
No
Are you a registered sex offender?
*
Yes
No
Are you being sponsored by an organization for rent assistance?
*
Yes
No
Do you have current monthly Income?
*
Yes
No
What are your sources of Income?
*
Veteran Benefits
Employed (Self-Pay)
SSI Benefits
Self Employed
Private Pay
Family Assistance
Other
What is your monthly Income?
*
$500 - $1,000
$3,000 - $4,000
$1,000 - $2,000
$5,000+
$2,000 - $3,000
Other
What is you desired move-In timeframe?
*
1-2 Weeks
1-3 Months
3-4 Weeks
6 + Months
Other
How did you hear about us?
Facebook
Instagram
Local Advertisement
Property Sign
Referred by a Friend
Other
List Name and Number of emergency contacts:
Submit
Should be Empty: