Tenancy Application – Tenant

Please note that all the fields except ‘Languages’ are required to submit the form.

Tenant Details

First Name(s)

Surname

Email Address

Contact Address
Address Line 1

Address Line 2

City

State

Main Contact
Phone number

Please Include your area code

Is this your home, mobile or office number?

Do you want to add another contact number? NoYes

Second Contact
Phone number

Please Include your area code

Is this your home, mobile or office number?

Date of Birth (DD/MM/YY):

Day:

Month:

Year:

Place of Birth

Income Source

Does Public Trustee deal with your finances?
YesNo

Referred by

Tenant Physical Health Problems Requiring Special Attention

(e.g. diabetes, epilepsy or other)

CRN Number

Medicare Number

Expire Date (MM/YY):

Month:

Year:

Do you have ambulance cover?
YesNo

Interests and Hobbies

Work History

Languages
First Language

Second Language

Reasons for wanting long term community living

Requested Tenancy Commencement (DD/MM/YY):

Day:

Month:

Year:

Tenant Next of Kin details

Full Name

Relationship

Contact Details

Main Contact
Phone number

Please Include your area code

Is this your home, mobile or office number?

Do you want to add another contact number? NoYes

Second Contact
Phone number

Please Include your area code

Is this your home, mobile or office number?

By submitting this form I consent to the release of any information about me, as required by the Administration of Emmaus Community, in order to assess my application for tenancy and assist my living in the Community. All personal information is securely disposed of if applicant doesn’t join Emmaus Community. I understand that this is independent community living and that I must be able to live independently to reside at Emmaus