Bloom Lake Flats Housing Application Form
The housing application for individuals with HIV/AIDS is completely confidential. We respect applicants’ privacy and ensure their information is securely protected.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Eligibility Requirements
Are you HIV/AIDS Positive?
*
Yes
No
What is your Monthly Income?
*
Do you have a Waiver through the State?
*
Yes
No
I just applied
If yes, please provide your case manager’s name & contact information below
Case Manager Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
What type of apartment are you looking for
*
Studio
One-bedroom
Two-bedroom
Consent for Background Check
A background check is required to process your application. If you do not consent, we cannot proceed with your Housing Application.
*
I consent to a background check.
I do not consent
Applicant’s Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: