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Henry Ford Hospital Apartments Housing Application

To apply for HFH Apartments Housing, please print or type all information on this form and

submit this one‐page application form to the HFH GME Office. You will be notified when a unit

is available for you.

Name: (Last, First)

Address/Street/Apt.:

City/State/Zip

Email Address:

Telephone: (where we may contact you)

Home:

Cell:

Program Department:

PGY (1, 2, 3, etc.):

Date of Birth (DOB):

I would like to request the following apartment as indicated below

Rank your preference for apt size and floor location with a “1” being your first choice; use a “0”

to indicate an option you would not consider.

Apt Size:

1 bedroom

Floor Preference:

03 ‐ 07

2 bedroom

08 ‐ 14

15 ‐ 21

Requested Move‐in Date:

Expect to Vacate:

Name, relationship and age (for children) of dependents who will reside with you during your

training, including spouse if applicable:

Names

Relationship

Ages

Deposits:



A $100 non‐refundable deposit is due when we confirm that housing is available, to hold your apartment.

This will be applied to your Security Deposit.



The following refundable deposits are due at move‐in:



Security Deposit equal to one month’s rent



Key Deposit of $10



A Cleaning Deposit of $200 (1 bedroom) and $250 (2 bedrooms)



These deposits are refundable based on condition of the apartment when vacated.

Housing will be confirmed by email. If you have any questions or want to cancel your request, please contact the

Apartment Coordinator (313) 916‐3297 or dclark2@hfhs.org .

V. 2/15/13

Diversity Information Page 26

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