YOUR NEXT STEP TOWARD FEELING AT HOME

Guest Application

Tell Van and Helen about your household and the home you’d like to rent.

$3,550 per month · Two-month minimum

Utilities, Wi-Fi, TV, lawn service, maintenance, and parking included.

Fields marked * are required. You can review your application before sending. Complete all other applicable fields. Enter N/A where a text field does not apply. Please do not enter payment information.

01 · Applicant

First name *Middle name / initial *Last name *

02 · Current address

Street address *City *State / province *ZIP / postal code *Country *Do you own or rent? *How long at this address? *

03 · Identification & contact

Social Security numberID / driver’s license numberIssuing state / countryID photoAttach this file yourself when sending your email. The page does not upload it.Email *Phone *Preferred contact method *

04 · Deposit return address

Use your current address? *

Street address *City *State / province *ZIP / postal code *Country *

05 · Employment

Employment status *

Employer / business *Position / occupation *Length of employment *Employer phone *Employer email *Street address *City *State / province *ZIP / postal code *Country *

06 · Emergency contact

Please name someone who will not be staying with you.

Name *Relationship *Phone *Email *Street address *City *State / province *ZIP / postal code *Country *

07 · Co-applicant

Is there a co-applicant? *

Social Security numberID / driver’s license numberFirst name *Middle name / initial *Last name *Email *Phone *Street address *City *State / province *ZIP / postal code *Country *Employment status *

Employer / business *Position / occupation *Length of employment *Employer phone *Employer email *Street address *City *State / province *ZIP / postal code *Country *

08 · Home & stay

All homes are $3,550 per month. A two-month minimum stay applies. Dates and home availability must be confirmed by Van and Helen.

Home applying for *Arrival date *Expected departure date *

09 · Other occupants

List everyone staying in the home besides the applicant and co-applicant. Include each child’s age.

10 · Pets

Most homes are pet friendly. Please confirm the pet arrangements for your selected home.

Will you bring pets? *

Type, breed, size, age, and number of pets *

11 · Vehicles

Include the vehicles that will be parked at the property.

12 · Stay requirements

Share only what helps us prepare the home. Medical diagnoses and treatment records are not needed.

Accessibility or other practical requirements *Additional comments *

13 · Review & acknowledgment

This is a guest application, not a reservation or rental agreement. Van and Helen will review your details and confirm availability and next steps. Any screening authorization and rental or deposit terms will be handled separately.

*I confirm that the information I provided is accurate to the best of my knowledge. *Applicant’s typed name *Date completed *

Your application stays on this page until you choose a sending or download option. It is not saved automatically. SSN and ID details, if provided, will be included in the application you review, download, or prepare by email.

CHECK YOUR DETAILS

Review your application

The email button opens your email app. Review and send it there. If the email is too long or your email app does not open, download the application and attach it to an email to medcenterhome@gmail.com. This page does not send or store applications.

Need help? 713-478-6456 · medcenterhome@gmail.com