Application form | RestoraLife Haven

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RestoraLife Haven Housing Application Form

Please complete this application accurately. Completing this application does not guarantee housing placement.

Full Name:

Birthday

Gender

Phone:

Email

Current Address:

Emergency Contact

Name:

Relationsip:

Phone

Current Housing Status

Homeless

Shelter

Living with family

Living with Friends

Hotel/Motel

Transitional Housing

Other:

How long in current housing?

Reason for Seeking Housing

Household Members

Names | Relationship | Age

Employment Status:

Income Status

Employer:

Monthly Icome:

Income Source:

Support Services Needed

Case Management

Employment

Life Skills

Financial Literacy

Transportation

Mental Health

Recovery Services

Benefits Assistance

Other:

Disabilty

Mobility accommodations?

Medical Information

Yes

No

Yes

No

Additional medical information:

Previous Evictions?

Money owed to landlord?

Rental History

Yes

No

Yes

No

References

Reference 1:

Reference 2:

Phone:

I certify the information provided is true and complete.

I authorize RestoraLife Haven to verify the information provided.

Your Signature

Thank You for Reaching Out!

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