HOUSING APPLICATION
HOPE COMMUNITY LIVING
APPLICANT INFORMATION
Full Name:
Date Of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Address:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
ID Number:
ID Expiration:
Email Address:
example@example.com
SCREENING QUESTIONS
PLEASE CIRCLE EITHER YES OR NO
Do you have a steady source of income? (Job, SSI, SSDI)
Yes
No
Monthly amount: $
Are you capable of managing your daily living activities independently?
Yes
No
Are you currently using drugs or alcohol?
Yes
No
Do you have any pets? (Pets are not permitted in program housing)
Yes
No
Any history of violent behavior or criminal convictions?
Yes
No
If yes, explain:
Do you require any special medical care or daily assistance?
Yes
No
Are you willing to follow all house rules and respect fellow residents?
Yes
OR
No
How did you hear about us?
Agency Referral
Social Media
Word of Mouth
Other:
APPLICANT AGREEMENT
By signing below, I certify that all information provided is true and accurate. I understand that false information will result in immediate denial or termination. I agree to follow all program rules, pay rent on time, and respect fellow residents and staff.
Resident Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Program Director Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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