INFORMATION SHEET
[Please Print Neatly]
Name:
Date of Birth:
Address:
How long have you lived at this address?
Previous Address (if less than 3 years or if you were displaced due to Hurricane Katrina):
Home Phone:
Work Phone:
Cell Phone:
SSN:
Services needed:
Reason for services:
Name of employer:
Title:
Work address:
Position:
Salary:
Length of employment
May we contact your employer? Yes / No
Name
of employer:
Title:
Work address:
Position:
Salary:
Length of employment
May we contact your employer? Yes / No
RELOCATION SERVICES
APPLICANT MUST RECEIVE A MONTHLY CHECK TO BE ELIGIBLE FOR THIS PROGRAM.
Name of landlord:
____________
Phone: _______________
Names, birth dates, relationship, and gender of family members
who will also be relocating:
Name: ___________________________ DOB: __________
Relationship: ____________ Male / Female
Name: ___________________________ DOB:
__________ Relationship: ____________ Male / Female
Name: ___________________________
DOB: __________ Relationship: ____________ Male / Female
Name: ___________________________
DOB: __________ Relationship: ____________ Male / Female
Name: ___________________________
DOB: __________ Relationship: ____________ Male / Female
Who
will be responsible for the monthly rent/mortgage payments?
Type of monthly check(s) you receive (i.e., disability, retirement, etc.)? ______________________________
Amount of
each check(s): ____________ ____________
____________ ____________
Are you
interested in renting or buying? _______________
Have you ever owned a home before? Yes / No
If yes, when? ____________________________
First relocation choice (state): _____________________________________________________________
Second relocation
choice (state): ___________________________________________________________
How soon can you relocate?
_____________________________
All information provided above is true, and I will advise ATWINDS within 10 days
of any changes to my information. If any information is found to be false, the contract between Client
and ATWINDS may become void, and Client will be responsible for any costs incurred.
Client
Date
Client
Date
Approved
Date
