Stayzy LLC Housing Application

Stayzy LLC Housing Application

All information will be kept confidential. Only one application per person.
Things to consider before applying

This is a shared housing living arrangement. Guaranteed Income is required (SSI/SSDI/Organization Pay) Individuals must be work- ready (Private Pay) House Rules are strictly enforced. Stayzy is a drug & alcohol-free environment
Participants Full Name*

First NameMiddle NameLast Name
Representative's Name

First NameLast Name
Rep's Organization (ex: DSS, Salvation Army, VA, etc)
Gender*
Date of birth*

MonthDayYear
Date
CaucasianAfrican AmericanHispanicAsianNative AmericanIslander
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Living w/ a friendLiving in a carLiving in a shelterLiving on the streetsHospital/FacilityShared Housing/Group homeOther
Reason for leaving current living situation?
Please be detialed
Do you have any physical or mobility issues? If yes, please explain below.*
Your answer will not disqualify you.
Do you require a Handicap Accessible living environment? If yes, please explain below.*
Your answer will not disqualify you.
Are you an ex-offender? If yes, please explain below.*
Your answer will not disqualify you.
Are you currently on Probation or Parole? If yes, please explain below.*
Your answer will not disqualify you.
Parole or probation officer contact information.
Desired Move-in Date*

MonthDayYear
Date
Employment/Funding Status*
If you selected unemployed or other please explain your ability to pay participant fee.
Please be detailed.
Place of employment & Job title/description
Monthly Income (USD)*
Can you provide proof of income or funding?*
Employer name & contact information
Are you willing and able to follow all program rules and respect others?*
Personal References (Name, Relationship, Contact Info)*
A minimum of 2 people
How did you hear about Stayzy?
Additional Comments
Should be Empty:

Stayzy LLC Housing Application

Things to consider before applying