Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone

(###)

###

####

Address Me By *

Please check this box if you prefer to not be addressed by your legal name, and only referred by your preferred name

Please ONLY use my preferred name

It's ok to address me by my legal name

Current Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Anticipated Move In Date *

MM

DD

YYYY

Projected Move Out Date *

MM

DD

YYYY

Landlord's Phone *

(###)

###

####

Supervisors Name *

First Name

Last Name

Start Date *

MM

DD

YYYY

End Date

MM

DD

YYYY

Employers Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Supervisors Phone # *

(###)

###

####

Previous Supervisors Name *

First Name

Last Name

Supervisors Phone # *

(###)

###

####

Previous Employers Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Start Date *

MM

DD

YYYY

End Date *

MM

DD

YYYY

Contact

First Name

Last Name

Phone

(###)

###

####

Contact

First Name

Last Name

Phone

(###)

###

####

Contact

First Name

Last Name

Phone

(###)

###

####

MOVE IN DATE

MM

DD

YYYY

MOVE OUT DATE

MM

DD

YYYY

RENT

$

Name of Property Manager

First Name

Last Name

Email of Property Managers

Phone

(###)

###

####

Previous Address #3

List Full Address #3

MOVE IN DATE

MM

DD

YYYY

MOVE OUT DATE

MM

DD

YYYY

RENT

$

Name of Property Manager

First Name

Last Name

Email – Property Manager

Phone

(###)

###

####

List Previous Address #4

List Full Address #4

Name of Property Manager

First Name

Last Name

MOVE IN DATE

MM

DD

YYYY

MOVE OUT DATE

MM

DD

YYYY

RENT

$

Email – Property Manager

Phone

(###)

###

####

References

1. Reference Name *

First Name

Last Name

Email *

Phone *

(###)

###

####

Years Known *

2. Reference Name *

First Name

Last Name

Email *

Phone *

(###)

###

####

Years Known *

Emergency Contact

Name *

First Name

Last Name

Email *

Phone *

(###)

###

####

Background

Have you ever been convicted of a crime (except driving citation) within the past 10 years? *

YES

NO

Have you ever been evicted or been to court because of an eviction? *

YES

NO

If you answered yes to either of the questions above, please explain:

Applicant understands and agrees that if he/she makes incorrect or misleading statements or omissions on this form, applicant will forfeit his/her eligibility for membership. *

Yes

No

Applicant understands and agrees that he/she has only applied for membership. This form is not a lease which may be accepted or rejected by the Co-op. *

Yes

No

Applicant hereby grants to Park Cooperative Apartments full authorization necessary to verify the information on this form, included but not limited to check criminal history, rental history, information from public agencies, work references, personal references, and other information relevant to this application for residential membership. *

Yes

No

Introduce Yourself *

Please share a brief introduction about yourself to our interview committee.

Why do you want to live at Park Cooperative Apartments? *

What is your vision for the type of community you would like to live in? *

What gifts, skills or resources could you contribute to the co-op that would help reach your vision of an ideal community? *

What experiences have you had working with a group and making decisions communally? *

What experiences have you had working with diverse groups of people? *

What other volunteer experiences or skills would you like to tell us about? *

How did you hear about us? *