INFORMATION SHEET

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Name:                                                                                      Date of Birth:                           

Address:                                                                                                                                  

How long have you lived at this address?                                   

Previous Address (if less than 3 years or if you were displaced due to Hurricane Katrina):

Home Phone:                                                                Work Phone:                                        

Cell Phone:                                                                               SSN:                                        

Services needed:                                                                                                                      

Reason for services:                                                                                                                 

Name of employer:                                                                    Title:                                        

Work address:                                                                                                              

Position:                                                                                    Salary:                         

Length of employment               May we contact your employer?            Yes / No

Name of employer:                                                                    Title:                                        

Work address:                                                                                                              

Position:                                                                                    Salary:                         

Length of employment               May we contact your employer?            Yes / No

RELOCATION SERVICES

APPLICANT MUST RECEIVE A MONTHLY CHECK TO BE ELIGIBLE FOR THIS PROGRAM.

Name of landlord:                                              ____________                        Phone: _______________

Names, birth dates, relationship, and gender of family members who will also be relocating:

Name: ___________________________   DOB: __________   Relationship: ____________   Male / Female

Name: ___________________________   DOB: __________   Relationship: ____________   Male / Female

Name: ___________________________   DOB: __________   Relationship: ____________   Male / Female

Name: ___________________________   DOB: __________   Relationship: ____________   Male / Female

Name: ___________________________   DOB: __________   Relationship: ____________   Male / Female

Who will be responsible for the monthly rent/mortgage payments?                                               

Type of monthly check(s) you receive (i.e., disability, retirement, etc.)? ______________________________

Amount of each check(s): ____________          ____________            ____________            ____________

Are you interested in renting or buying?  _______________

Have you ever owned a home before? Yes / No                If yes, when? ____________________________

First relocation choice (state): _____________________________________________________________

Second relocation choice (state): ___________________________________________________________

How soon can you relocate? _____________________________

All information provided above is true, and I will advise ATWINDS within 10 days of any changes to my information.  If any information is found to be false, the contract between Client and ATWINDS may become void, and Client will be responsible for any costs incurred.

                        Client                                                                            Date

                        Client                                                                            Date

Approved                                                                      Date