First Name

Last Name

Birthday

Social Securty #

Current Address

Phone

Current Employer

Other source of income?

Why are you looking for housing?

Start Date Needed

Emergency Contacts

Address

Relationship

Phone

Status of Recovery

Any Mental Health issues past or present? Do you receive services?*

Any Chemical dependencies past or present? Are you receiving services?*

Provide Incarceration or Arrest history and/or Any charges pending? In what county?

Probation/Parole Officer Name & Number

Additional Comments

I understand I am applying to be a Guest/licensee of THCC HOUSING and NOT a tenant. Upon approval, THCC HOUSING will give me a license to use a bed and no other legal rights to stay on the property. NO TENANCY WILL BE CREATED. Absolutely no landlord/tenant relationship exists between Guest and THCC HOUSING.

I've read and accept terms & conditionsView terms

Your Signature

Date

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