Application For Housing

Name of Applicant (required)

Street Address Apt. No.

Street City/Town State Zip

Home Phone Work Phone

Cell Phone

Please indicate the best phone number to reach you: Home Work Cell

Mailing Address

Email (required)

MEMBERS OF HOUSEHOLD TO LIVE IN UNIT (including Head of Household):

Member 1 First & Last Name Relation Occupation

Member 2 First & Last Name Relation Occupation

Member 3 First & Last Name Relation Occupation

Member 4 First & Last Name Relation Occupation

Member 5 First & Last Name Relation Occupation

HOUSEHOLD INCOME

Based on your most recent tax return, what is your approximate household income?

$0 - $55,000$56,000 - $72,000$73,000 - $89,000$90,000 - $130,000$131,000+

HOUSING HISTORY

List addresses for each adult household member for at least the last 5 years in reverse order, please list primary leaseholder, if other than you.

(1) Current Address: Years: Name of Landlord/Owner Phone: Address of Landlord/Owner Primary Leaseholder

(2) Previous Address: Years: Name of Landlord/Owner Phone: Address of Landlord/Owner Primary Leaseholder

EMPLOYMENT HISTORY

List employment history for each adult household member for at least the last 5 years in reverse order, please list primary leaseholder, if other than you.

MEMBER 1 (EMPLOYEE)

(1) Current Employer: Years: Employer Address: Employer Phone: Dates of Employment: Name of Supervisor: Monthly Pay:

(2) Previous Employer: Years: Employer Address: Employer Phone: Dates of Employment: Name of Supervisor: Monthly Pay:

MEMBER 2 (EMPLOYEE)

(1) Current Employer: Years: Employer Address: Employer Phone: Dates of Employment: Name of Supervisor: Monthly Pay:

(2) Previous Employer: Years: Employer Address: Employer Phone: Dates of Employment: Name of Supervisor: Monthly Pay:

PERSONAL REFERENCES

List two references. These should not be relatives or household members. It is strongly recommended that all applicants also submit character reference letters to the Walsh Park Board of Directors.

(1) Name: # of years you have known this person: Address: Phone:

(2) Name: # of years you have known this person: Address: Phone:

COMMUNITY INVOLVEMENT

Walsh Park properties are only made available to year-round residents of Fishers Island who are active, contributing members of the community. Please list examples of your community involvement:

OTHER

Why does the applicant want to live in Walsh Park housing? What special skills does the applicant offer to the Fishers Island community? Please list any additional reasons you’d like the Walsh Park Board of Directors to consider in their review of your application:

APPLICANT CERTIFICATION

I/we certify that if selected to participate in the program, the unit I/we occupy will be my/our only residence. I/we understand that the above information is being collected to determine my/our eligibility.

I/we authorize the Walsh Park Benevolent Corporation and its representatives to verify all information provided on this application and to contact previous or current landlords, employers or other sources of credit and verification information.

I/we certify that the statements made in this application are true and complete to the best of my/our knowledge and belief. I/we understand that false statements or information may result in my/our losing access to Walsh Park Benevolent Corporation’s housing program.

Signature of Applicant: Date:
Signature of Co-Applicant: Date: