Application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastPhoneDate Email *Emergency Contact Name *FirstLastEmergency Contact Phone NumberHousing Needs Desired Move-In DateHow soon are you looking for housing?ImmediatelyWithin 1-2 WeeksWithin 30 daysJust exploringEmployment Status & Financial Information Employement Status EmployedSeeking EmploymentOtherPrimary Source of IncomeEmployment IncomeFamily SupportProgram Assistance / Voucher (Please Specifiy)Legal & Background Pending Legal IssuesNoYes (Please Specify)Violent Crime / Sex OffenderYesNo Source rules? conditions? Shared Living Expectations Willing to follow house rules?NoYesMedical Any medical conditions?NoYesAre you taking any presciption medication?NoYesGoals & Intentions What are your goals for recovery and independent living? *Anything else you would like us to know?Acknowledgement Application Acknowledgement *I agree to the Terms and Conditions listed below: *• This is a substance-free living environment (no drugs or illegal activity permitted) • Residents are expected to follow all house rules, policies, and community expectations • Respectful behavior toward other residents and staff is required at all times • Providing false or misleading information may result in denial of application or removal from the program • Carlson Community Housing reserves the right to enforce policies to maintain a safe and stable environmentSubmit
