Waitlist Application

CSH Wait List Form

General Information:

First name

Last name

Phone

Select a date

R10 Staff Name and Phone Number (if applicable):

Qualifying Questions:

1. Does someone in the household have a disability?

Select an option

Yes

2. What is the average houshold income?

Does the household receive rental assistance?

Select an option

Yes

If yes, please list type of assistance and who administers it:

3. Has anyone in the household ever been convicted of manufacturing drug?

Select an option

Yes

Been convicted of distribution of hard drugs in the last 10 years?

Select an option

Yes

Been convicted of anything violent in the last 3 years?

Select an option

Yes

Is anyone in the household on the sex offender registry?

Select an option

Yes

Additional Information:

1. When do you need to move?

2. We have a preference on our waiting list for people who receive services through Region Ten. Does someone in the household receive Region Ten services?

Select an option

Yes

3. How many people are in your household?

Select an option

4. How many bedrooms do you need?

Select an option

5. Do you need to avoid stairs?

Select an option

Yes

6. Do you require an accessible unit?

Select an option

Yes

Thank you for your interest in Community Services Housing. If you do not hear from us within 3 months, give us a call just before that time and ask for the leasing specialist to extend your time on the list so that we will know that you are interested in remaining on the waiting list. If you do not call us before the 3-month mark, your name will be taken off the waiting list.

Thanks

Community Services Housing, Inc.

Thanks for submitting!

Community Services Housing, Inc. is a 501 (c) (3) non-profit organization.

Federal ID: 54-1578644

PHONE: 434-978-2007

FAX: 434-978-2136

1001 E Market Street Suite 102

Charlottesville, Virginia 22902

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