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Rental Application - Pathway to Care Housing

Resident Rental Application

Please complete all sections clearly and in full. Completion of this application does not guarantee acceptance. All information provided is subject to verification.

Section 1 — Applicant Information

Full Legal Name

Date of Birth

Social Security # (last 4)

Phone Number

Email Address

Current Address

City / State / ZIP

Emergency Contact

Emergency Contact - Relationship

Emergency Phone

Emergency Contact - Alt. Phone

Section 2 — Housing Request

Preferred Move-In Date

Estimated Length of Stay

Room Preference

Shared

Private (if available)

Section 3 — Income & Funding

Monthly Income

Other Income Source

Receiving Housing Assistance?

Yes

If yes, Agency / Program

Requesting Pathway Rental Subsidy?

Yes, requesting

Section 4 — Employment

Employer Name

Position / Job Title

Monthly Employment Income

Employer Phone

Section 5 — Background Information

Pathway to Care Living Solutions conducts background screening on all applicants. Answering yes to any question below does not automatically disqualify you. Each response will be reviewed individually.

Felony conviction?

Yes

If yes, explain

Pending charges?

Yes

Sex offender registry?

Yes

Section 6 — Health & Accessibility

Accessibility accommodations needed?

Yes

If yes, describe

Allergies / Emergency Medical Conditions (optional)

Currently under physician care?

Yes

Primary Care Physician & Phone

Currently taking prescription medications?

Yes

If yes, medication list required

Section 7 — References

Please provide two personal or professional references (not family members).

Reference 1 — Full Name

Reference 1 — Relationship

Reference 1 — Phone

Reference 2 — Full Name

Reference 2 — Relationship

Reference 2 — Phone

Section 8 — Applicant Certification

I certify that all information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that providing false or misleading information may result in denial of this application or termination of residency. I authorize Pathway to Care Living Solutions to verify the information provided, including conducting a background and/or credit check if applicable.

Applicant Printed Name (serves as your electronic signature)

Date