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? MobileHomeOffice 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? MobileHomeOffice 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? MobileHomeOffice 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? MobileHomeOffice 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