Housemate Application Your Information Name Address Address Line 1 Address Line 2 City--Select State--AlabamaAlaskaArizonaArkansasArmed Forces AmericaArmed Forces EuropeArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState or RegionUnited StatesCanada Country* Zip Email Home Phone Cell Phone Work Phone Best number to call during the dayHomeCellWorkThere are typically 4 times as many people looking for housing as there are homes available. We cannot guarantee that everyone will find housing through our program. What is the maximum rent per month you would pay? What pets do you have? If you own a dog, has it ever bitten anyone?YesNoCurrent Housing Situation If other, please explainRentOwnOther Explanation of current housing situationHow long at current address? From To If renting, current landlord's name and numberWe ask for the following information to help determine that RappHomeShares does not discriminate in its services. Gender Date of Birth Age Do you have a disability?YesNo Do you receive Medicaid?YesNo Annual income (must include all sources of income)ReferencesAll references should be people who have known you at least 1 year. Together, the references should cover a span of at least 5 years to the present. We require references from past or present roommates, employers, or co-workers. NOT ACCEPTED as references are family members, friends, or romantic partners. Tell your references that RappHomeShares will be calling them. If you have trouble reaching them, we will have the same trouble, and your application will be delayed. Reference 1 Daytime phone City State Email How long have they known you? How do they know you? Reference 2 Daytime phone City State Email How long have they known you? How do they know you? Other information you want us to know Is there another adult seeking housing with you?YesNo Acknowledgment I hereby acknowledge that all the information I have given in this application is true and complete to the best of my knowledge and belief. I understand that providing any false or misleading information will make me ineligible for the services of RappHomeShares. I agree Signed
