KEENSCROSSING.pdf


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#4’s Previous Employer or Income Source:
Name of Employer/Source of Income:
Address:
Phone #:
Position:
Other sources of Income:
Applicant #

Employment Dates:
Salary:

Type of Income

Source/Bank

Gross Annual Amount

Has any applicant ever been evicted from their home for any reason?
If yes, please give details:

YES

NO

Has any applicant ever been arrested, charged or convicted of any crime?
If yes, please give details:

YES

NO

Does any applicant currently have any criminal charges pending against them? [ ] Yes [ X] No
If yes, please give details:______________________________________________________________________
___________________________________________________________________________________________
Are you or any member of your household subject to a lifetime sex offender registration requirement in any state?
[ ] Yes [ X] No

_____________________

Emergency Contact/Relatives (not to be residing with you):
1. Name: GREG LIGHT
Address:
2. Name:

Relationship: FATHER

PLAINFIELD, VT

Phone: 802-839-8878
Relationship:

Address:
3. Name:

Address:

Applicant#:
Phone:

Relationship:

Address:
4. Name:

Applicant #: 1

Applicant #:
Phone:

Relationship:

Applicant #:
Phone: