Applicant Full Name *
Date of Birth *
Spouse Full Name
Spouse Date of Birth
Primary Phone *
Primary Email *
Current Address or Living Situation:
If Employed, Employer's Address:
StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
How long have you been employed with this company?
Do you receive Social Security, SSI, SSDI, or Cash Aid? *
Do you receive Cal-Fresh or WIC benefits? *
Total monthly net income? (include wages)
Car Payment (monthly):
Car Fuel (gas):
Cell Phone Bill:
If yes, note year eviction(s) that took place in the last 5 years.
Have you ever been convicted of a felony?
If yes, when and please describe.
Pets are not allowed.
How did you hear about EMM?
I agree and understand the statement above
EMM relies on the information given above to be complete and accurate in order to act on the application in a timely manner. Any false statements, misrepresentations, inaccurate information or failure to supply the data requested above may serve as grounds for rejection of the application. By checking the box, you certify that all information contained in this application is true, correct and complete to the best of your knowledge.