Please print out application for

Please print out application form and complete. Mail it to our Main Office’s address listed below

Application for Housing

Port of the Islands Senior Resort

12323 Union Road

Naples, FL 34114

Main Phone: 239-394-7700

Phone: 954-993-8278 mobile (Mr. Raj)

Personal Information

Please list all family members who will reside in residence.

	Full Name	Relationship	Sex	Age	Birthdate	SSN
1.		Head of Household				N/A
2.		Co-Head/Spouse				N/A
3.

HOME TELEPHONE NUMBER: ____________________________

How did you hear about Port of the Islands Senior Resort? _______________________

_______________________________________________________________________

Housing History

Please provide the last 5 consecutive years of addresses and landlord history:

	CURRENT ADDRESS	PRIOR ADDRESS	PRIOR ADDRESS
STREET
CITY
STATE/ZIP
OWN OR RENT?
PAYMENTS TO
PAYMENT AMOUNT
LENGTH AT ADDRESS
LANDLORD NAME
LANDLORD ADDRESS
MANAGERS PHONE #
REASON FOR LEAVING

　

　

Vehicle Information

	Driver Name	Drivers License #	Make/Model	License Plate #	Year	Color
1.
2.

Do you know anyone currently residing at the residence? _______________________

Indicate, by checking, your housing situation within the past 2 years:

Standard

Substandard

Shared Housing

Shelter

Protective Shelter

Personal References of two people not related to you:

1. Name__________________________________

Address City/State/Zip____________________________________________________

Day Telephone ( ) ______________________

Occupation Relationship___________________________________________________

2. Name__________________________________

Address City/State/Zip____________________________________________________

Day Telephone ( ) ______________________

Occupation Relationship___________________________________________________

Do you have any pets over 10lbs? Yes No

If yes, explain in detail:

Have you ever applied or lived here before? Yes No

Have you ever filed for bankruptcy? Yes No If yes, Date:

Have you ever been evicted from tenancy? Yes No If Yes, Date & Reason:

Have you willfully or intentionally ever refused to pay rent? Yes No If Yes, Reason:

Have you or any member ever lived in any assisted housing? Yes No If yes, when:

I certify the above information to be true and correct to the best of my knowledge. I authorize verification of assets, income, credit history, rental history and references. I understand that falsification of information found before or after acceptance of this property includes penalties that will result in cancellation of your application, also to include eviction, loss of assistance, if applicable.

　

___________________________________ ____________________

Head of Household Date

　

___________________________________ ____________________

Co-Head of Household Date

　