Are you having problems getting rental housing?

Your Name *

First Name

Last Name

Your Phone Number *

Please provide a good phone number so we can follow up with you.

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Emergency Contact Phone number *

A good phone number for your emergency contact.

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Emergency Address *

An address where a 6 month follow up is likely to reach you. This will help you receive the additional 12 months of Ready to Rent validation.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Race *

Check any and all that apply (for informational purposes only)

American Indian/Alaskan Native

Black/African American

White

Asian

Native Hawaiian/Other Pacific Islander

Other

Ethnicity *

Hispanic

Non-Hispanic

Gender *

Male

Female

Transgender

Age *

16-24

25-35

35-50

50-65

65 and above

Unknown

Are you disabled? *

Yes

No

Are you now, or have you ever been on Probation or Parole *

Yes

No

Which best describes your household? *

Extended Family (Living with relatives)

Grandparents and Children

Single Parent-Female

Single Parent-Male

Single-Female

Single-Male

Two Adults with children

Two Adults without children

Unaccompanied Youth

Houshold size *

1

2

3

4

5

6

7

8 or more

Where do you currently live? *

Check one box

Rent

Shelter

Hotel/Motel with voucher

Hotel/Motel without a voucher

On the street/in a car

Own my own home

Transitional Housing

Friends/Family

Jail/Prison

Drug & Alcohol Treatment

Other

Where did you live before? *

Check all that apply.

Rent

Shelter

Hotel/Motel with voucher

Hotel/Motel without a voucher

On the street/in a car

Own my own home

Transitional Housing

Friends/Family

Jail/Prison

Drug & Alcohol Treatment

Other

Rental Barriers *

Please check all that apply.

Eviction on record

Owe prior landlord money

Criminal History

Bad Credit

Bad rental reference

Alcohol/Drug problems.

Do not have money for move in costs or rent

I have never been a renter

How did you hear about Ready to Rent? *

Friend/Family

Community Agency/Case Worker

Salem Housing Authority

Do you currently have a Section 8 Voucher?

Yes

No

Are you currently on a waitlist for a Section 8 Voucher?

Yes

No

When did you apply for a Section 8 Voucher waiting list, if applicable.

leave blank if you are not on a waiting list.

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