LandLord

LandLord Name: Unison Health

Address: 1425 Starr Avenue, Toledo OH 43605

Phone: (419)936-7356

 

Rental Property Information

The term of the tenancy will be Month to Month: 
The monthly rent will be:

  • 30% of income up to $100 month for transitional housing
  • 30% of income up to $300 month for independent housing with a security deposit of $150

Applicant's Personal Information

Applicant's Name
Social Security Number
Date of Birth
Phone
Alternative Phone
Email(Optional)
Marital Status
 single  married
 divorced  separated
 
Is English your primary language
 yes
 no
If no, what is your primary language?
Are you a US Citizen?
 yes
 no
Are you a Veteran
 yes
 no
List all medical conditions
List all allergies
List all medications
Are you recieving Mental Health or Substance Use Services currently?
 yes
 no
if yes where?
What is your sobriety date?

Residential History

Present Address
City
State
Zip
How long at this Address?
Landlord/lessor?
Landlord/lessor phone?
 
Previous Address
City
State
Zip
How long at this Address?
Landlord/lessor?
Landlord/lessor phone?
 

Details of Employment

Employer
Position
Hire Date
Supervisor's Name
Phone
Salary

(if employed less than one year with present employer, please provide previous employer.)

Employer
Position
Hire Date
Supervisor's Name
Phone
Salary

Other Sources of Income

Do you receive income from any source other than employment?
 Yes
 No
If yes: list source, amount and frequency

 


Vehicle Information

Make/Model
Year
License Plate Number
Driver's License Number
Parking stall required?
 yes
 no

Banking Information

Banking Intituion
Bank Address
Bank Phone

References

Name
Phone
Name
Phone

Emergency Contact

Name
Relationship
Phone

Criminal & Credit Background Check Authorization 

Is there anything negative that we may find in our criminal or credit background check that you want to comment on?

I declare that the information I have provided is accurate. I authorize the individual or organization to whom this application is submitted to: (a) contact my references and all other persons that I have named in this application; and (b) perform a credit and/or criminal check to assess my suitability as a tenant/lessee.

Please type your name as your digital signature
Date