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Birthday
Month
Day
Year
Will you or do you currently receive housing assistance?
Yes
No
Are you willing to undergo through a background check?
Yes
No
Have you ever been evicted?
Yes
No
Do you have any criminal convictions within the last 7 years?
Yes
No
Do you currently use any drugs or alcohol?
Yes
No
If your application is accepted, are you willing to submit to a drug & alcohol test?
Yes
No
Are you currently in recovery?
Yes
No
Do you currently attend treatment or meetings?
Yes
No
Are you willing to share a bedroom?
Yes
No
Will you need move in assistance?
Yes
No
Preferred Location:
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Date
Month
Day
Year
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