Get A Room – Ace Pathway Solutions

First Name

Last Name

Date of Birth

Gender

Male

Female

Phone/Mobile

Current Address/Location

House Address

City

State

How long have you lived at your current address?

I am applying as a:

Senior / Elderly Individual

U.S. Military Veteran

Individual Re-Entering Society

Other

Branch of Service

Dates of Service

VA Benefits Status

Expected release date or current status

Probation/Parole Officer Name and Contact

When do you need housing?

Immediately (within 2 weeks)

Within 1 month

Within 2–3 months

Just exploring options

Have you visited or toured our facility?

Yes

I want to schedule a tour

Current employment status

Employed

Unemployed

Primary source of income

If other…please specify

Approximate monthly income

Do you have a housing voucher

Yes

If Yes, What Type

Have you been convicted of a felony or misdemeanor?

Yes

If Yes: Please briefly describe

Are you a registered sex offender?

Yes

Are you currently using any illegal drugs, alcohol, or tobacco/nicotine products?

Yes

Are you currently in a substance recovery program?

Yes

Are you willing to submit to a substance screening test as part of the admissions process?

Yes

Sleep schedule

Early riser

Night Owl

No Preference

Noise level preference

Very quiet

Moderate

No preference

Any other preferences or accommodation needs?

Reference 1 Name

Relationship

Phone/Mobile

Emergency Contact Name

Relationship

Phone/Mobile

I confirm that all information provided in this application is true and accurate to the best of my
knowledge. I understand that providing false information may result in denial or revocation of
admission.

I acknowledge that submitting this form does not guarantee admission to Ace Pathway Solutions
and that my application is subject to review, screening, and approval.

I consent to Ace Pathway Solutions conducting a background check and substance screening as
part of the admissions process.

I have read and understood the Ace Pathway Solutions Privacy Policy.

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