Section 1 of 5

Personal Information

Please provide accurate personal information. All submissions are confidential and used only for housing screening purposes.

First Name *

Last Name *

Date of Birth *

Gender

Phone Number *

Email Address

Current Address *

How Long at Current Address?

Reason for Moving

Emergency Contact

Emergency Contact Name *

Relationship

Emergency Contact Phone *

Emergency Contact Email

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Section 2 of 5

Housing Preferences

Tell us what you're looking for so we can match you with the right room and location.

Room Preference

Housing Type *

Veteran Housing — Private Room Veteran Housing — Shared Room Independent Adult — Private Room Independent Adult — Shared Room

Are You a Veteran? *

Yes No

Branch of Service (if applicable)

Preferred Service Area *

Target Move-In Date *

Do You Have Any Pets?

No Yes

Do you have any criminal history? *

No Yes

If yes, please briefly describe (nature, date, disposition)

Page 2 of 5

Section 3 of 5

Income & Payment

This information helps us confirm eligibility and match you with a room within your budget. All information is kept strictly confidential.

Monthly Income Amount

Employment Status

Employer / Agency Name (if applicable)

Do you currently have a representative payee or financial guardian?

No Yes

If yes, rep payee / guardian name and contact

Are you able to live fully independently without daily support or supervision? *

Yes, I am fully independent No, I require daily support

Important Notice
Pure Vantage Group provides housing only. We do not provide medical care, supervision, or support services. Residents must be able to manage their own daily activities independently.

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Section 4 of 5

References & History

Please provide at least one personal or professional reference. Case managers, social workers, or prior landlords are preferred where applicable.

Reference One

Full Name *

Relationship *

Phone

Email

Reference Two (Optional)

Full Name

Relationship

Phone

Email

Referral Source

How did you hear about Pure Vantage Group?

Referring Agency or Organization (if any)

Anything else you'd like us to know?

Page 4 of 5

Section 5 of 5

Agreement & Signature

Please review and acknowledge the following before submitting your application.

Applicant Agreement

By submitting this application, I acknowledge and agree to the following:

1. All information provided in this application is true and accurate to the best of my knowledge. I understand that providing false information may result in disqualification or termination of tenancy.

2. I understand that Pure Vantage Group provides independent living shared housing only. No medical care, supervision, treatment, or support services are provided. I am responsible for managing my own daily activities.

3. I understand that submission of this form does not guarantee housing placement and that all applicants are subject to a screening process.

4. I consent to Pure Vantage Group contacting my listed references for the purpose of housing screening.

5. I agree to abide by the house rules of any property in which I am placed. Violations of house rules may result in lease termination.

6. I understand that my personal information will be kept confidential and used only for housing screening purposes. I have read and agree to the above terms. I confirm that all information in this application is accurate.

Full Legal Name (Signature) *

Today's Date *

Page 5 of 5

Resident Intake Form

Personal Information

Housing Preferences

Income & Payment

References & History

Agreement & Signature

Applicant Agreement

Application Received