INTAKE APPLICATION
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Email *
WHAT LOCATION ARE YOU APPLYING FOR?
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WHO IS THIS APPLICATION FOR? 
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APPLICANT INFORMATION
FIRST & LAST NAME *
PHONE NUMBER *
CURRENT ADDRESS *
If you do not have a physical address, please put N/A
SSN# OR DRIVER'S LICENSE # *
INCOME/EMPLOYMENT INFORMATION
CURRENT EMPLOYER *
SUPERVISOR'S NAME & CONTACT INFORMATION *
MONTHLY INCOME *
DO YOU HAVE AN EBT CARD? IF WHAT DATE DO YOU RECEIVE BENEFITS AND HOW MUCH DO YOU RECEIVE? *
DO YOU RECEIVE SOCIAL SECURITY OR VA BENEFITS?IF SO, WHAT'S THE MONTHLY INCOME AMOUNT? *
PREVIOUS RESIDENTIAL HISTORY
WHAT'S YOUR CURRENT LIVING SITUATION? *
LANDLORD'S FIRST & LAST NAME *
LANDLORD'S PHONE NUMBER *
MONTHLY RENT *
REASON FOR LEAVING *
HOUSING PREFERENCES
ARE YOU AWARE THAT THIS IS A SHARED LIVING RESIDENCE? *
HOW SOON ARE YOU LOOKING TO MOVE?
WHAT IS YOUR BUDGET? *
WHAT TYPE OF ROOM DO YOU PREFER? *
HAVE YOU EVERY LIVED IN SHARED HOUSING BEFORE? *
HOW LONG WOULD YOU LIKE TO BE A RESIDENT OF OUR HOME?  *
BACKGROUND INFO
HAVE YOU EVER WILLFULLY REFUSED TO PAY RENT WHEN DUE? *
HAVE YOU EVER BEEN EVICTED FROM TENANCY OR LEFT OWING MONEY? IF YES, PLEASE PROVIDE PROPERTY NAME, CITY, STATE, & LANDLORD NAME.  *
HAVE YOU EVER BEEN CONVICTED OF A SEXUAL CRIME? IF YES, PLEASE PROVIDE THE TYPE OF OFFENSE, COUNTY, AND STATE.  *
LIST YOUR CURRENT MEDICATIONS *
ARE YOU ADDICTED TO ALCOHOL OR OPIODS? IF SO, ARE YOU IN A TREATMENT PROGRAM? *
CRIMINAL HISTORY  *
IF YES, PLEASE PROVIDE DETAILS OF ANY CRIMINAL CHARGES OR CONVICTIONS YOU HAVE, INCLUDING THE NATURE OF THE CHARGES AND ANY ASSOCIATED LEAGAL OUTCOMES. 
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DO YOU HAVE A PROBATION OFFICER, ETC? IF YES, WHAT IS THEY NAME, PHONE NUMBER, EXTENSION?
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OTHER INFORMATION
VEHICLE INFORMATION- MAKE/ MODEL/YEAR/LICENSE #/ & STATE *
EMERGENCY CONTACT- PLEASE LIST NAME, ADDRESS, PHONE, & RELATIONSHIP  *
PERSONAL REFERENCES- PLEASE LIST NAME, ADDRESS, PHONE, & RELATIONSHIP  *
AUTHORIZATION
I/we, the undersigned, authorize Bridgeway Communities, LLC, and its agents to obtain an investigative consumer credit report
including but not limited to credit history, OTIS search, landlord/tenant court record search, criminal record search and registered sex offender search. I authorize the release of information from previous or current landlords, employers, and bank representatives. This investigation is for resident screening purposes only and is strictly confidential. This report contains
information compiled from sources believed to be reliable, but the accuracy of which cannot be guaranteed. I hereby hold Bridgeway Communities, Landlord and its agents free and harmless of any liability for any damages arising out of any improper use of this information.
Important information about your rights under the Fair Credit reporting Act:
• You have a right to request disclosure of the nature and scope of the investigation.
• You must be told if information in your file has been used against you.
• You have a right to know what is in your file, and this disclosure may be free.
• You have the right to ask for a credit score (there may be a fee for this service).
• You have the right to dispute incomplete or inaccurate information. Consumer reporting agencies must correct
inaccurate, incomplete, or unverifiable information.
A summary of your rights under the Fair Credit Reporting Act is available by visiting or writing (Para information en espanol,
visite o escribe): http://www.ftc.gov/credit
Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Avenue N.W., Washington D.C. 20580

PLEASE TYPE YOUR FIRST & LAST NAME BELOW TO AUTHORIZE
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