Office Use Only Unit Size Requested Unit Number Targeted Move-In Date Date Received Time Received _C__o__k_a__t_o__P__a__r_k_v__i_e_w____________________________ _2__6_0___T__h_i_r_d__S__t_r_e__e_t__S__o__u_t_h__w__e__s_t_____________ _C__o__k_a__t_o_,__M___N___5_5__3_2__1_________________________ _P__h__:_(_3__2__0_)__9__0_5__-_2__8_7__4________________________ APPLICANT INFORMATION Applicant Name (Head of Household): Address: Social Security Number: Date of Birth: [ ] Male [ ] Female [ ] Decline Applicant Phone #: Applicant Email: Alternate Phone #: Alternate Email: Emergency Contact: List All Other Household Members First MI Last Relationship to Head Date of Birth Male/Female/ Decline to Answer Social Security Number [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline Primary Language: Do you require an interpreter? [ ] Yes [ ] No How did you hear about this housing? [ ] Online [ ] Newspaper [ ] Local Agency [ ] Drive By [ ] Resident Referral [ ] Other What is the combined gross monthly income of all household members? $ ADDITIONAL HOUSEHOLD MEMBERS CURRENT HOUSING STATUS How long have you lived at your current address? From: To: Is this family or a friend? [ ] Yes [ ] No Name of Owner/Manager: Phone #: Email: Address: Do all adult household members live at this address?........................................................................................................................ [ ] Yes [ ] No If NO, include additional adult household’s current address and contact information on a separate piece of paper. PREVIOUS HOUSING STATUS Your previous address: How long did you live at your previous address? From: To: Is this family or a friend? [ ] Yes [ ] No Name of Owner/Manager: Phone #: Email: Address: List every state in which each household member has lived: ELIGIBILITY INFORMATION
For Office Use Only Ref No )
Acceptance of Services Not a Waiver The City’s acceptance of any service or deliverable is not a waiver or release of any professional duty of care applicable to such service or deliverable, or of any right of indemnification, any insurance requirements, or any other term or condition of this Master Agreement.
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Certification of Meeting or Exceeding Tobacco-Free Workplace Policy Minimum Standards A. Grantee certifies that it has adopted and enforces a Tobacco-Free Workplace Policy that meets or exceeds all of the following minimum standards of:
i. Prohibiting the use of all forms of tobacco products, including but not limited to cigarettes, cigars, pipes, water pipes (hookah), bidis, kreteks, electronic cigarettes, smokeless tobacco, snuff and chewing tobacco;
ii. Designating the property to which this Policy applies as a "designated area,” which must at least comprise all buildings and structures where activities funded under this Grant Agreement are taking place, as well as Grantee owned, leased, or controlled sidewalks, parking lots, walkways, and attached parking structures immediately adjacent to this designated area;
iii. Applying to all employees and visitors in this designated area; and
iv. Providing for or referring its employees to tobacco use cessation services.
B. If Grantee cannot meet these minimum standards, it must obtain a waiver from the System Agency.