Please complete pre application inquiry form for approval Name * First Name Last Name Email * Contact Number Gender Male Female Decline to answer Please select Race Caucasian African American Asian American indian Islander Date of Birth MM DD YYYY Select Current Living Situation Living a/ a friend Living in a car Living in a Shelter Incarcerated Hospital/ Facility Shared Housing/ Group Home What type of room do you prefer? Shared Private When do you need to be placed? You will you be paying rent? Job Income SSI/SSDI Voucher Organization Funding Other Monthly Income? If none, please type NONE Do you suffer from mental illnes? Yes No If Yes, enter mental diagnosis: Are you disabled? Yes No Do you require a handicap accessible living environment? Yes No Have you ever been convicted as a sex offender? (Your answer does not disqualify you from housing opportunities or services) Yes No With 1000 Ft Restriction Without 1000 Ft Restriction How did you hear about us. Referral Search Engine/ Web Social Media Word of Mouth Do you prefer a particular area? Yes No If YES, please let us know where below? Phone (###) ### #### Thank you!
