Dignity Housing Authority

Apply for housing @ Dignity Heal Life Center, LLC
Serving the Rochester, NY area.

Applicant Information

Full Name: Date of Birth: SSN: Driver's License Number: Email Address: Phone Number:

Address: Monthly Rent: Lease Start: Lease End: Reason for Moving: Landlord Name: Landlord Phone: Landlord Email:

Occupation: Employer: Start Date: Gross Monthly Income: Supervisor Name: Supervisor Phone: Supervisor Email:

Reference 1 - Full Name: Relationship: Phone: Email: Reference 2 - Full Name: Relationship: Phone: Email:

Upload ID: Upload Proof of Income:

I certify that I am over 18 and all info is accurate. I authorize screening, background checks, and contact with past landlords and employers.

Signature: Date: Print Name: