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Intake Application

Please complete every section as fully as you can. Fields marked with an asterisk are required. All information is kept confidential.

Intake ApplicationVeterans Residential Housing

01Applicant Information

First name

Middle name

Last name

Date of birth

Last 4 of SSN

Gender

Phone

Current address or location (if any)

Current living situation

02Military Service

Branch

Service start

Service end

Discharge type

Rank at separation

DD-214 available?

Yes No Requested

VA disability rating?

Yes No Pending

Rating percentage (if applicable)

VA facility / case manager

03Income & Benefits

Sources of income (select all that apply)

Total monthly income ($)

Employer (if employed)

04Housing & Background

Have you ever been evicted?

Yes No

Are you a registered sex offender?

Yes No

Any felony convictions?

Yes No

Currently on probation or parole?

Yes No

If you answered yes to any question above, please explain

Previous addresses (last 2 years) and reason for leaving

05Health & Support Needs

This helps us make sure the home is a good fit and that you have the support you need. Answers do not automatically disqualify an applicant.

Do you take prescribed medications?

Yes No

Can you manage your own medications?

Yes No

Mobility or accessibility needs?

Yes No

In substance-use recovery?

Yes No Prefer not to say

Anything we should know to support you (accommodations, allergies, service animal, etc.)

Do you have a vehicle?

Vehicle make / model / plate

06Emergency Contact & Referral

Contact name

Relationship

Contact phone

How did you hear about us?

Referring agency / person

Desired move-in date

07Certification & Consent

I certify that the information in this application is true and complete. I understand that false or missing information may result in denial or termination of occupancy. I authorize Wilson-Randolph Holdings to verify my veteran status, income, rental history, and background, including through VA and public records. I have read, or will read before move-in, the Rules & Regulations.

Applicant signature

Sign above

Printed name

Date