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Affordable Shared Housing Waiting list Form
* Indicates required question
Email
*
Your email
Referring Agent
*
Your answer
Request Move-in Date
*
MM
/
DD
/
YYYY
Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Social Security
*
Your answer
Email Address
*
Your answer
Driver's License Number/State
*
Your answer
Phone Number
*
Your answer
Income Information - Amount & Date Paid (ex. SSI/SSDI/VA Benefits/Other)
*
Your answer
Do you Have or Have You Had a Felony or Misdemeanor? Please Explain Details Below.
*
Your answer
Do you Smoke?
*
Yes
No
Do you Have Transportation?
*
Yes
No
Please Let Us Know How Long You Would Like To Be a Resident?
*
Your answer
Emergency Contact Name & Number
*
Your answer
A copy of your responses will be emailed to the address you provided.
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