| * = Required Field | Please enter as much information as you can. |
| Name: * | |
| Address (Street or P.O.): * | |
| City: * |
State: *
Zip: * |
| Have you ever resided at or applied for CARE Housing before?
Yes No If yes, when?
|
| Home Phone:* |
Work Phone:
Cell Phone: |
| E-mail Address: | |
| How did you hear about CARE Housing? |
|
| (Name of agency, person, publication, etc.) | |
| Number of Adults:* |
Number of Children:*
|
|
| Are any adults full-time students? |
Yes
No |
| Employer(s): | |
| Average hours worked per week:* | Rate of pay:*
per*
|
| Average hours worked per week: | Rate of pay:
per
|
|
Any other source of income: (Child Support, Spousal Support, SSI, etc.)
|
| Do you have any past due account other than medical or student loans? (landlords, utility companies, etc.)
Yes
No;
|
| If yes, please describe. | |
| Have you ever been evicted?*
Yes
No |
| Do any adults in the household have judgments filed against them?*
Yes
No |
| Have you filed bankruptcy within the last year?*
Yes
No |
| If yes how long ago? |
|
| Does anyone in the household have a felony conviction?*
Yes
No |
| If yes how long ago? |
|
| Does anyone in the household have misdemeanor conviction (other than traffic)?*
Yes
No |
| If yes how long ago? |
|
| Is anyone in the household currently on probation, parole, or serving a deferred sentence?*
Yes
No |
| Do you have any pets?*
Yes
No |
| If yes what type? |
|
| When would you like to move in?* |
|
| Which property are you most interested in?* |
|
|
1303 West Swallow Road, Building 11  Fort Collins, CO 80526 970-282-7522 FAX 970-282-7524
www.carehousing.org info@carehousing.org
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