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Online Housing Application

Housing Screening

Full Name(*)
Please let us know your name.

Your Email
Please let us know your email address.

Phone Number(*)
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Date of Birth(*)
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Last 4 digits of Social Security Number(*)
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Gender(*)
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Race(*)
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Marital Status(*)

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City(*)
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Spouse Name
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Spouse Date of Birth
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Are you currently homeless(*)

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Briefly explain your current living situation.(*)
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Have you previously been in a shelter or housing program?(*)

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If yes, when and where?(*)
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Are you currently employed?(*)

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Do you own a car?(*)

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Do you have a valid driver's license?(*)

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Do you or any member of your family have any special health needs?(*)

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If yes, please list and explain(*)
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Have you ever been treated for or hospitalized for mental health issues?(*)

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If yes, what were you treated for?(*)
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When?(*)
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Have you ever been treated for alcohol or substance abuse?(*)

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Is your family currently in a domestic violence situation?(*)

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Have you ever been convicted?(*)

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Have you or your spouse ever been convicted?(*)
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Type of conviction(*)
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Are you pregnant?(*)
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Please list the members of your family in need of housing, along with their age and gender.....(*)
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If we are not able to provide you with services at this time, do we have your permission to share your information with other agencies that could possibly assist you?(*)
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