The Brunswick Housing Authority
1126 Albany Street Angela Strickland, Executive Director
Brunswick, Georgia 31521-1118
Telephone: (912) 265-1334
Fax: (912) 265-1280
TDD: (800) 255-0056
Application for Locally Owned Units
Date:______, 20____Client # : ______
Housing Choice: Please check your preference
Hopkins Annex: 1 Bedroom - $375 2 Bedroom - $415 3 Bedroom - $475
Brooklyn Annex: 1 Bedroom - $375 2 Bedroom - $415 3 Bedroom - $475
Personal Information:
First Name:______Mid. Initial: ___ Last Name: ______
Current Address: ______
City: ______State: ____ Zip: ______
Home Phone: (____)______-______Cell Phone: (____)______-______
Work Phone: (____)_____-______Email Address: ______@______
Marital Status: Single MarriedDivorcedSeparated
Landlord Reference:
Landlord Name: ______
Landlord Address: ______
City: ______State: ____ Zip: ______
Landlord Phone: (____)______-______Email Address: ______@______
Prior Residency:
*Previous Address #1:: ______
City: ______State: ____ Zip: ______
Landlord Name: ______
Landlord Address: ______
City: ______State: ____ Zip: ______
Landlord Phone: (____)______-______Email Address: ______@______
Reason for leaving: ______
*Previous Address #2:: ______
City: ______State: ____ Zip: ______
Landlord Name: ______
Landlord Address: ______
City: ______State: ____ Zip: ______
Landlord Phone: (____)______-______Email Address: ______@______
Reason for leaving: ______
Current Employer:
Employer Name: ______
Employer Address: ______
City: ______State: ____ Zip: ______
Hourly Wage: $ ______How Often Paid: Weekly Bi-Weekly Monthly 2x Monthly
List last three (3) employers:
*Employer Name: ______Contact Person: ______
Address: ______Phone: (____)______-______
City: ______State: ____ Zip: ______
*Employer Name: ______Contact Person: ______
Address: ______Phone: (____)______-______
City: ______State: ____ Zip: ______
*Employer Name: ______Contact Person: ______
Address: ______Phone: (____)______-______
City: ______State: ____ Zip: ______
Questions:
Have you ever received a dispossessory warrant (eviction)? Yes No
Have you ever been convicted of a felony? Yes No
Have you ever been convicted of a misdemeanor? Yes No
Are you a registered sex offender? Yes No
Contact Information:
List nearest relative not living with you:
Name: ______Relationship to You: ______
Address: ______Phone: (____)______-______
City: ______State: ____ Zip: ______
List Everyone That Will Occupy The Unit:
1)First Name:______Mid. Initial: ___ Last Name: ______
Male Female DOB: ___/___/_____ SSN: ____-___-_____ Race:______
Relationship to Head of Household: ______
2)First Name:______Mid. Initial: ___ Last Name: ______
Male Female DOB: ___/___/_____ SSN: ____-___-_____ Race: ______
Relationship to Head of Household: ______
3)First Name:______Mid. Initial: ___ Last Name: ______
Male Female DOB: ___/___/_____ SSN: ____-___-_____ Race: ______
Relationship to Head of Household: ______
4)First Name:______Mid. Initial: ___ Last Name: ______
Male Female DOB: ___/___/_____ SSN: ____-___-_____ Race: ______
Relationship to Head of Household: ______
5)First Name:______Mid. Initial: ___ Last Name: ______
Male Female DOB: ___/___/_____ SSN: ____-___-_____ Race: ______
Relationship to Head of Household: ______
List All Sources of Household Income:
SS * SSI Benefits: $ ______Pension: $______TANF: $_____
Child Support: $_____ Employment: $______Unemployment:$_____
Other (explain): ______
______
I do hereby swear and attest that the above information is true and correct:
Signature of ApplicantDate: ______, 20___
Signature of Spouse or Other AdultDate: ______, 20___
Signature of Other AdultDate: ______, 20___
Affirmative Action / Equal Opportunity Employer