Application

Shared Housing Application

Please fill out the form below completely and honestly. All information is kept strictly confidential.

Personal Information

Full Name

Date of Birth

Current Address

Phone Number

Email Address

Social Security Number

Best Time to Reach

Sex at Birth

Male Female

Emergency Contact

Contact Name

Relationship

Phone Number

Address

Employment & Income

Are you currently employed?

Yes No

Employer Name

Position

How long employed?

Hours per week

Next Pay Date

Pay Frequency

If not employed, Income Source

Total Income Amount ($)

Background

Ever convicted of a crime?

Yes No

Any pending charges?

Yes No

If yes to either, please provide details

Lifestyle & Recovery

Have you ever been evicted?

Have you ever broken a lease?

Do you smoke?

Do you use illegal substances?

Are you currently in recovery?

Do you have a sponsor?

If yes, Sponsor Info (Name / Phone)

Do you have a social worker?

Social Worker Contact Details

Medical

Do you have a mental illness?

Has it been formally diagnosed?

Are you taking medication?

Can you self-administer meds?

Please list any medical conditions

Accessibility & Additional Info

Do you require a live-in aide/nurse?

Are you currently expecting?

Do you have accessibility needs?

If yes, please explain your accessibility needs

Agreement

Note: A $300 non-refundable program fee is required.

I agree to the terms and certify that all information provided in this application is true and correct to the best of my knowledge.

Digital Signature (Type Full Name)

Today's Date

Application Submitted!

Thank you for applying to Lovely's Home LLC. We have securely received your information. Lovely will review your application and be in touch with you soon regarding the next steps.