Application To Rent Form Page 5
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6Please Type or Print Neatly in Blue or Black Ink
Each Proposed Tenant Must Fill Out a Separate Application
ARE YOU CURRENTLY HOMELESS? Yes No
1. Are you living in a place not meant for human habitation? (i.e.the street, parks, sidewalks or
abandoned buildings)?
_____________________________
Yes No If yes, please describe: ____
__________________________________________________________________________________
2. Are you sleeping in an emergency shelter or living in transitional housing for the homeless after
living on the streets or an emergency shelter? Yes No If yes, please describe: ___________
__________________________________________________________________________________
3. Are you residing in any of the places in (# 1 or 2 above) and now staying in a hospital or other
institution for up to 30 consecutive days? Yes No If yes, please describe: _______________
__________________________________________________________________________________
4. Are you being discharged within a week from an institution that you have resided in for more
than 30 consecutive days; or being evicted within a week from a private dwelling; or fleeing a
domestic violence situation and in all cases no subsequent residence has been identified and you
lack the resources and support networks needed to obtain housing? Yes No If yes, please
describe: __________________________________________________________________________
INCOME INFORMATION
Monthly Income
Source of Income
$
$
$
Total Monthly Income: $ ____________________
Please indicate all types of Social Security benefits i.e. SSI, SSD, SSA, etc. ____________________________
PERSONAL REFERENCES
1.__________________________________ ________________________________________________
Name
Address (Street, City, State, Zip)
(_______)____________ ____________________ _______________ _________________________
Phone
Relationship
Length of Acquaintance Occupation
2.__________________________________ ________________________________________________
Name
Address (Street, City, State, Zip)
(_______)____________ ____________________ _______________ _________________________
Phone
Relationship
Length of Acquaintance Occupation
ADDITIONAL INFORMATION
Have you ever been convicted of a crime other than an infraction? Yes No
If yes, for each conviction attach a separate sheet with all information about dates, locations, courts
of conviction, case numbers, offenses, sentences or other dispositions. If you are on probation please
include the name and contact information of your probation officer.
Hollister Apartments Rental Application, rev. 1/2016
Application Page 3 of 4
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