HOUSING

Name *Enter First and Last Name

Email Address *Please provide a reliable email address.

Phone *Please provide a reliable contact number.

Arrival Date *

Estimated move-in date.

Length of Stay *3-6 months6-12 months12 months or longerAnticipated length of stay.

Emergency Contact *Please list next of kin that may assist you throughout this process, or in the event of an emergency.

Relationship to Emergency Contact *

Do you have a payee? *YesNoA payee is a responsible party in an exchange of goods or services who receives and makes payments.

If no, will you allow Infinity Gardens to be your payee? *YesNoNote: payments for Infinity Gardens services are direct drafted. We do not accept cash payments.

Do you receive monthly income such as SSI, retirement or similar income? *YesNo

Describe income and enter amount ($0 or Greater)?Infinity Gardens understands every perspective tenant’s situation varies and we strive to work with your individual circumstances by taking all factors into consideration to provide maximum accommodations.

Do you have government issued documents? *State issued identification (I. D./Driver License)Birth CertificateSocial Security CardNone of the aboveSelect all that apply.

Services Needed? *Housing/Room AccommodationsEmployment AssistanceOtherIdentify support services Infinity Gardens can assist you with obtaining. Select all that apply.

Do you have a disability? *YesNo

If yes, please briefly describe disability?

Special dietary needs?List any food allergies, diabetes, etc.

Employment SkillsList key skills and qualities that are useful with obtaining gainful employment.

HOUSING

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