Apply Now Apply now to secure your spot on the waiting list for a rental space at Anchor of Trust Homes Name * First Name Last Name Date of Birth MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone (###) ### #### What services are you interested in? Shared Room Private Room Are you currently homeless? Yes No Are you currently living in supportive housing Yes No Do you have a current lease or housing ? Yes No Do you have any physical disabilities? Yes No Do you have any cognitive impairments? Dementia , memory loss Yes No Do you require assistance with daily activities ? Bathing, dressing, ect Yes No Are you currently receiving any home care or support services? Yes No If yes, please specify Have you had any recent history of violent behavior? Yes No Do you have any current or pass issues with substance abuse? Yes No Do you have any felony convictions ? Having a felony conviction will not automatically disqualify you from the program. Each application is reviewed individually with the consideration of the nature of the offense, time elapsed and rehabilitation efforts. Yes No If so please provide details of your felony convictions below. Are you willing to comply with house rules and participate in a community living setting ? Yes No Do you have monthly Income ? Yes No Thank you for your application. A member of our team will contact you regarding the next steps
