Anchor House Application

Applicant Information

First Middle Last

Preferred Name (If different from legal name)

Pro-Nouns (e.g. her(s), he/him/his, they/them)

Social Security Number

Date of Birth

Driver's License No.

Driver's License State

Expiration Date

Primary Phone

Secondary Phone

Only to be filled out if applicant has a child:

Child's Full Name (If Applicable)

Child's Age

Rental History

Most Recent Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

How long at this address?

Monthly rent amount:

Was your rent up to date?

Yes

Landlord' Name

Phone

Lease Expiration

Reason for Leaving

Previous Address

How long at this address?

Monthly rent amount:

Was your rent up to date?

Yes

Landlord' Name

Phone

Lease Expiration

Reason for Leaving

Have you ever been evicted?

Yes

Employment History

Current Employer

Position

Supervisor's Name

Supervisor's Phone

Supervisor's Email

Monthly Gross Income

Lenght of Employment

Previous Employer

Position

Supervisor's Name

Supervisor's Phone

Supervisor's Email

Monthly Gross Income

Lenght of Employment

Vehicle Information

Make

Model

Year

License Plate

Foster Care History

County Department

Caseworker Name

Caseworker's Phone

Caseworker's Email

Date Left Care

Most Recent Chafee Worker Name

Chafee Worker's Email

Chafee Worker's Phone

References

Full Name

Relationship

Phone

Full Name

Relationship

Phone

Full Name

Relationship

Phone

Banking/Credit History

Bank Name

Savings Account #

Balance

Checking Account #

Balance

Have you ever been convicted of any criminal offense(s) other than traffic violations?

Yes

Name of Person Assisting with Application (If Applicable)

Phone

Agreement and Authorization

I hereby certify that I am at least 18 years of age and that the statements above made are true and correct. Applicant authorizes credit, background, and reference checks and releases from liability any person providing or obtaining information and/or verification related to this application. Applicant understands that this is a rental application and not a lease agreement.

Applicant Signature

Date

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