The Haven Quarters:
Room Rental Application
Comfortable, Convenient & Quality Shared Living
Personal Information
First Name
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Last Name
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Phone
*
Format: (000) 000-0000.
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Do you have a valid ID?
*
Applicant Current Address
Current Address
Street Address Line 2
City
State
ZIP Code
Gender Identity
*
Please Select
Female
Male
Emergency Contact Full Name
Relationship
Emergency Contact Phone
Format: (000) 000-0000.
Emergency Contact Address
Address
Street Address Line 2
City
State
ZIP
Do you authorize The Haven Quarters to contact the emergency contact listed on this application in the event of an emergency or urgent situation involving your health, safety, or well-being? Yes or No
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Health & Support Needs
Do you have any physical disabilities? If yes, please specify.
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Do you depend on health care staff to provide daily care services? If yes, please provide company name.
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Do you require a reasonable accommodation or modification related to your housing?
Do you have any accessibility needs that should be considered when selecting a room?
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Do you currently take medications?
Do you smoke?
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Do you have a history of alcohol or drug abuse? If yes, describe?
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Do you have allergies of any kind? food, pets, dust etc
Applicant Background
Registered sex offender? If yes, explain.
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Felony convictions? If yes, explain.
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If you have had a Felony convictions? Please provide date of most recent conviction.
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Ever been evicted? If yes, explain
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Income & Benefits
Do you currently receive any benefits or financial assistance? If yes, please list all benefits you currently receive (for example: SSI, SSDI, SNAP/Food Assistance, TDAP, Veterans Benefits, Unemployment, etc.). If none, please enter “None.”
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Are you currently employed? If yes, please provide the name of your employer and indicate whether you are able to provide proof of employment and/or income upon request.
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How often do you receive income (weekly, biweekly, monthly, etc.)?
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If employed, provide working hours per week
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How much is your income per month?
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Are you able to provide documentation verifying your income or ability to pay?
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Are you able to consistently make your monthly housing payment on time, based on the rental rate for your selected room?
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Do you understand that, prior to move-in, you are required to pay the applicable non-refundable move-in fee and your first month’s housing payment in full?
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Transportation
Do you currently have reliable transportation?
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Will you be bringing a vehicle to the property?
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Will you be using public transportation?
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Community Living
How would you describe your personality and preferred living environment? For example, are you more social and outgoing, quiet and reserved, or a combination of both? Please share anything that would help us understand your living style and compatibility with a shared-home environment.
*
How would you describe your typical cleanliness and housekeeping habits?
Please Select
Very tidy and organized
Generally clean and tidy
Average
I may need occasional reminders with cleaning and organization
Are you comfortable participating in the cleaning and upkeep of shared/common areas?
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Is there anything about your lifestyle or schedule that you believe other residents should reasonably be aware of?
Are you willing and able to follow The Haven Quarters' policies regarding respectful conduct, threats, violence, harassment, and the safety of other residents?
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Anything else you would like to share?
What does being a respectful roommate mean to you?
Referrals
Were you referred by agency or individual? Please provide name.
Agency or individual phone number
Format: (000) 000-0000.
Signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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