First and last name: *

Phone number: *

Email: *

Address (including city, state & ZIP code): *

Languages spoken fluently other than English, if any:

Contact information for someone we can contact if we are unable to reach you: *

Do you use social networking media such as Facebook or LinkedIn? *

Are you a real estate agent, landlord, or property manager? *

Is your spouse or partner a real estate agent, landlord, or property manager? *

Have you ever been convicted of a felony? *

Have you ever been convicted of a crime involving fraud or perjury? *

Will you require any reasonable accommodation to attend a training or to conduct testing? If yes I will contact you once I have received your application to discuss any accommodations you may require. *

Please describe your work & education history (if you have a resume you can insert it here): *

Employer (list if applicable):

Occupation (list if applicable):

Have you ever been dismissed from a job for misconduct involving dishonesty, fraud, or theft? *

How did you hear about our testing program? *

Have you ever engaged in "testing" for housing discrimination before?

If yes, for what agency or organization?

Are there specific towns, apartment complexes, realtors, or landlords you should not test because you may be recognized? *

If yes, please specify where you would be unable to test:

Do you have a car or access to one? *

Do you have typing and internet access from home? *

When would you be available to conduct testing (i.e. are there days of the week that are best for you? Would you only be able to test after work hours or do you have flexibility during the work day, etc.)? *

Name of Professional Reference *

Organization & Title/Occupation: *

Email: *

Phone #: *

Relationship to you: *