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Apply for Independent Living

Thank you for your interest in becoming a Member of our shared housing program. Please complete this short application so we can ensure this is a good fit.

Personal Information

Full Name

Date of Birth

Phone Number

Email Address

Current Living Situation

Where are you currently living?

Why are you looking for housing?

Employment / Assistance

Are you currently employed?

Yes No

Receiving assistance?

Yes No

Emergency Contact

Name

Phone

Membership Acknowledgment

I understand this is a membership agreement, not a lease or tenancy.

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