GLT Homes Housing Application
Thank you for your interest in GLT Homes. Please complete this application to inquire about housing availability. A member of our team will contact you regarding the next steps.
Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Current Housing Situation
Please Select
Renting
Staying with Family/ Friends
Shelter
Transitional Housing
Homeless
Other
Monthly Income Source
Please Select
Employment
SSI
SSDI
Veterans Benefits
Retirement
Other
Approximate Monthly Income
Example: $1200
Desired Move-In Date
-
Month
-
Day
Year
Date
Room Preference
Shared Room
Private Room (If Available)
Employment Status
Full-Time
Part- Time
Unemployed
Retired
Disabled
Were you referred by an agency or case manager?
Yes
No
Agency Name (if applicable)
Case Manager Name (if applicable)
Are you able to live independently and perform daily activities without personal assistance?
Yes
No
Preferred Method of Contact
Phone Call
Text Message
Email
Emergency Contact Name
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any mobility needs, disabilities, or special accommodations we should be aware of?
Questions or Comments
I certify that the information provided is true and accurate to the best of my knowledge and I authorize GLT Homes to contact me regarding housing opportunities.
Yes
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