Rental Form - Graceful Hearts Senior Living

Applicant first name *

Applicant last name *

Applicant address *

City applicant was born in

State applicant was born in

Phone *

Email

Applicant age *

Applicant D/O/B *

Applicant gender *MaleFemale

Does the applicant have an ID? or driver's license. * Enter the number in the "box".

Does the applicant have any prior felony convictions? *YesNo

If yes, Please note the charges.

Does applicant have a social security card? *YesNo

Applicant social security number

Does the applicant receive food benefits? *YesNo

Does the applicant receive SSI OR SSDI - Pensions or other type of incomes? Enter which income your receive in the "box".

What medications are you currently taking? If any and are you "compliant"?

What is the applicant's total monthly income? *

USD

How soon are you looking to move?

Why are you needing housing? How long have you been needing housing?

How do you ambulate (your movement of your body)

Do you have any medical conditions? If so what are they?

Does the applicant agree to stay for 1 month at a time or longer? *YesNo

Employment Information

Most recent Employer *

Street *

City *

State *

ZIP *

Supervisor Name *

Supervisor phone number *

Start date *

End date *

Years on job *

Landlord information

Landlord name *

Landlord phone number *

What was your rent amount? *

USD

Rental start *

Rental end *

Emergency information

Name *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.