I have read and understand the Facts and Procedures. Click Here to read Application Agreement.

NOTE:***All fields must be completed in full or request will not be processed***
Head of Household
First:
Middle Initial:
Last:
Date of Birth:
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SSN:
Home Number:
Cell Number:
Email:
Any other name(s) used (including maiden name: 
Employment Information
Current Employer:

Address:
City:
State:
Zip:
Phone Number:
  Ext:
Supervisor Name:

Supervisor Number:
  Ext:

Your Title/Position:

Monthly Income:
Start Date:
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Residential History
Current Address
Street1:
Street2:
City:
State: Zip:
Residency: Rent   Own   Living with Family
Landlord Name:
Phone:
Fax:
Email:
Previous Address
Street1:
Street2:
City:
State:
Zip:
Residency:
Rent   Own Living with Family
Background Information
Who were you referred by:

Are you currently a student?
Yes   No
Have you been a student in the last 12 months?
Yes   No
Are you currently homeless?
Yes   No
How many times have you been homeless?
Do you claim a mental disability?
Yes   No
Do you currently work with someone from Vera French?
Yes   No


Desired Monthly Rent ($390-$525):
Please choose housing choices in order to place you on the correct waiting list.
Supervised Living:
Yes   No

Number of Bedrooms?
One   Two
Handicap Accessible?
Yes   No
Can you get utilities in your name?
Yes   No
Do you have a current SEC 8 Voucher/ or other subsidy?
Yes   No
List Others Who Will Live With You
Please list all people who will reside in the residence: 

Please list any additional information you feel is relevant:
Application Completion

I authorize Vera French Housing to verify the information provided on this form as to my employment history, mental health diagnosis, and criminal background check.

I, the undersigned Applicant, agree to the above terms and do hereby swear (or affirm) that the information supplied herein is true and complete, to the best of my knowledge and belief.  By clicking "Apply Now" you agree to the terms stated above.  Please enter your full name to signify your digital signature, thereby confirming that you have read and agree with all the above statements and have provided complete and accurate information.  Applicant authorizes verification of references given and declares that the statements made in this application are true and correct and agrees that the landlord may terminate the contract entered into in reliance on any misstatement made in this application.


APPLICANT SIGNATURE: 



   
Database Info:  VERAFRCH_122253  VeraFrenchHousing