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    PATIENT REFERRAL TO ARK HOUSE

    Instructions:
    The following is a patient referral form for Ark House. If the information for a required field is not available (NA) you may enter "NA" or a field compliant response (e.g. NA@NA.com for the email). You will not be allowed to submit a referral with a required field blank.

    The calendar function for selecting dates does not work properly with Internet Explorer. You will have to type in the dates in Internet Explorer. It has been tested and works with Edge, Chrome, and FireFox.

    Required fields marked with an "*"

    Referral Date*: (mm/dd/yyyy)

    ======= PATIENT INFO =======

    Patient's Permanent Address* (Must be greater than 50 miles from Dallas):
    Street* :
    City* :
    STATE*:
    ZIP* :
    Country*:

    Enter Patient Date of Birth:
    Birth Month:* (Month: 1 to 12)
    Birth Day.....:* (Day: 1 to 31)
    Birth Year....:* (Year: 1910 to 2040)

    Date Apartment Needed*: (mm/dd/yyyy)

    Weeks

    U.S. Citizen with a SSN*:

    NOTE: All occupants in Ark House MUST be legal residents of the United States, there are NO exceptions!

    Foreign National Legal (Legally in the U.S.)?:
    Foreign Nationals MUST be in the U.S. legally with documents to reside in Ark House.

    ======= PRIMARY POINT OF CONTACT FOR PATIENT/FAMILY =======
    The person identified should be the primary point of contact for Ark House completing the application process and during the time the patient and/or family is residing in Ark House. The PPOC may be the patient, a family member, or a caregiver staying with the patient.

    Relationship to Patient:



    ======= REFERRER INFO =======

    Notes:
    ALL adult occupants (18 years or older), including patient and all caregivers, must have an SSN and pass a criminal background check. Foreign Nationals MUST be in the U.S. legally with documents to reside in Ark House.

    Ark House is set up for two residents at a time, with provisions for occasional visitors. A sleeper sofa provides for two additional residents and occasional guests.

    After reviewing your inputs and assuring all required fields have an input, you may check the box below and then submit the referral. You will receive an email verifying its submittal to Ark House.

    Please review your inputs, check the box, and then press the "SUBMIT REFERRAL" button.

    After submitting, scroll down to see the submittal confirmation message.





      ARK HOUSE APPLICATION

      A member of your family or a friend has been referred to Ark House by a medical facility providing treatment. This application is required to start the process of qualification for Ark House. The patient or their representative should have been or will be contacted by an Ark House representative to coordinate the application process.

      In fairness to all concerned, the patient will NOT be placed on the Ark House waitlist unless the following is completed within SEVEN (7) DAYS OF INITIAL CONTACT from Ark House following referral:

      This application is NOT complete without:
      1. Credit/debit card authorization for background checks.
      2. Legible photos of Government-issued photo IDs and all required documents are received by Ark House.
      3. Until background checks have been completed and application is approved by Ark House.

      =======================
      INSTRUCTIONS:
      Many fields in this form are REQUIRED.
      * Required Information
      ** Required if you have one!
      The required fields are noted with an "*" next to the field name. If the information in the required field is not applicable, you may enter "NA".
      =======================

      ======= PATIENT =======

      Please NOTE:
      The following information for the PATIENT is required even if they may not initially be staying in Ark House! Information on occupants other than the patient will be entered later in the form.

      FULL LEGAL NAMES are required for background checks! NO Nicknames. Thank You.

      GENDER: (Male/Female)

      PERMANENT HOME ADDRESS - WHERE YOU LIVE NOW:

      STATE*:

      DO YOU OWN OR RENT?* RentOwn

      Enter Date of Birth:
      Birth Month:* (Month: 1 to 12)
      Birth Day.....:* (Day: 1 to 31)
      Birth Year....:* (Year: 1910 to 2040)

      SOCIAL SECURITY NUMBER (SSN)**: (Enter "None" if person does not have a SSN)

      DRIVER'S LICENSE or Govt ID NUMBER*:

      U.S. CITIZEN*:


      MUST BE IN THE U.S. LEGALLY with documents to reside in Ark House.
      Legally in the U.S.?:

      Applicants must email copy of documents showing legal residence in the United States to Ark House at OCCUPANCY@ARKHOUSEDALLAS.ORG immediately after submitting application. Use your phone to take picture of document(s) and forward by email.

      A PERSON ILLEGALLY IN THE UNITED STATES MAY NOT STAY AT ARKHOUSE! Criminal background check can not be performed. Call Occupancy at (972) 671-7144 for additional information or clarification


      DO YOU SMOKE*: YesNo

      Smoking in Ark House apartment or other buildings is grounds for eviction!



      === OCCUPANT #2 / CAREGIVER ===
      ADD 2nd OCCUPANT?:

      FULL LEGAL NAMES are required for background checks! NO Nicknames. Thank You."

      GENDER: (Male/F-Female)



      Relationship to Patient:

      PERMANENT HOME ADDRESS - WHERE YOU LIVE NOW:

      STATE*:

      DO YOU OWN OR RENT?* RentOwn

      Enter Date of Birth:
      Birth Month:* (Month: 1 to 12)
      Birth Day.....:* (Day: 1 to 31)
      Birth Year....:* (Year: 1910 to 2040)

      SOCIAL SECURITY NUMBER (SSN)**: (Enter "None" if person does not have a SSN)

      DRIVER'S LICENSE or Govt ID NUMBER*:

      U.S. CITIZEN*:


      MUST BE IN THE U.S. LEGALLY with documents to reside in Ark House.
      Legally in the U.S.?:

      Applicants must email copy of documents showing legal residence in the United States to Ark House at OCCUPANCY@ARKHOUSEDALLAS.ORG immediately after submitting application. Use your phone to take picture of document(s) and forward by email.

      A PERSON ILLEGALLY IN THE UNITED STATES MAY NOT STAY AT ARKHOUSE! Criminal background check can not be performed. Call Occupancy at (972) 671-7144 for additional information or clarification



      DO YOU SMOKE*: YesNo

      Smoking in Ark House apartment or other buildings is grounds for eviction!



      === OCCUPANT #3 / CAREGIVER ===
      ADD 3rd OCCUPANT?:

      FULL LEGAL NAMES are required for background checks! NO Nicknames. Thank You."

      GENDER: (Male/F-Female)



      Relationship to Patient:

      PERMANENT HOME ADDRESS - WHERE YOU LIVE NOW:

      STATE*:

      DO YOU OWN OR RENT?* RentOwn

      Enter Date of Birth:
      Birth Month:* (Month: 1 to 12)
      Birth Day.....:* (Day: 1 to 31)
      Birth Year....:* (Year: 1910 to 2040)

      SOCIAL SECURITY NUMBER (SSN)**: (Enter "None" if person does not have a SSN)

      DRIVER'S LICENSE or Govt ID NUMBER*:

      U.S. CITIZEN*:


      MUST BE IN THE U.S. LEGALLY with documents to reside in Ark House.
      Legally in the U.S.?:

      Applicants must email copy of documents showing legal residence in the United States to Ark House at OCCUPANCY@ARKHOUSEDALLAS.ORG immediately after submitting application. Use your phone to take picture of document(s) and forward by email.

      A PERSON ILLEGALLY IN THE UNITED STATES MAY NOT STAY AT ARKHOUSE! Criminal background check can not be performed. Call Occupancy at (972) 671-7144 for additional information or clarification



      DO YOU SMOKE*: YesNo

      Smoking in Ark House apartment or other buildings is grounds for eviction!


      === OCCUPANT #4 / CAREGIVER ===
      ADD 4th OCCUPANT?:

      FULL LEGAL NAMES are required for background checks! NO Nicknames. Thank You."

      GENDER: (Male/F-Female)



      Relationship to Patient:

      PERMANENT HOME ADDRESS - WHERE YOU LIVE NOW:

      STATE*:

      DO YOU OWN OR RENT?* RentOwn

      Enter Date of Birth:
      Birth Month:* (Month: 1 to 12)
      Birth Day.....:* (Day: 1 to 31)
      Birth Year....:* (Year: 1910 to 2040)

      SOCIAL SECURITY NUMBER (SSN)**: (Enter "None" if person does not have a SSN)

      DRIVER'S LICENSE or Govt ID NUMBER*:

      U.S. CITIZEN*:


      MUST BE IN THE U.S. LEGALLY with documents to reside in Ark House.
      Legally in the U.S.?:

      Applicants must email copy of documents showing legal residence in the United States to Ark House at OCCUPANCY@ARKHOUSEDALLAS.ORG immediately after submitting application. Use your phone to take picture of document(s) and forward by email.

      A PERSON ILLEGALLY IN THE UNITED STATES MAY NOT STAY AT ARKHOUSE! Criminal background check can not be performed. Call Occupancy at (972) 671-7144 for additional information or clarification



      DO YOU SMOKE*: YesNo

      Smoking in Ark House apartment or other buildings is grounds for eviction!



      YesNo ... been evicted or asked to move out?
      YesNo ... left before lease expired without the owner's consent?
      YesNo ... declared bankruptcy?
      YesNo ... been sued for rent?
      YesNo ... been sued for property damage?>
      YesNo ... been convicted or received probation for a felony or misdemeanor crime?
      For any "YES" above, indicate below the person(s) who was responsible, year, location, and type of each felony or misdemeanor crime.

      ======= EMERGENCY CONTACT (Not Residing at Ark House) =======

      RELATIONSHIP (required):

      ======= GOVERNMENT ISSUED ID - SEND NOW =======

      Provide a photographic image (PNG or JPG) or photo of all persons listed on this application. It must be a valid (NOT Expired) driver's license or government-issued photo ID. Please confirm that the ID image is in focus and readable and the photo is recognizable. Email to occupancy@arkhousedallas.org or text to Ark House Occupancy at (972) 671-7144.

      ======= AUTHORIZATION =======

      I, the undersigned, have obtained permission from all applicant to authorize Ark House to obtain reports from any consumer or criminal record reporting agencies before, during, and after residency on matters relating to a lease by Ark House to me and to verify, by all available means, the information in this Application, including criminal background information, income history and other information reported by employer(s) to any state employment security agency. Work history information may be used only for this Application. Authority to obtain this information expires 365 days from the date of this Application.

      ======= ACKNOWLEDGEMENT =======

      You declare that all your statements in this Application are true and complete. Applicant's submission of this Application, including payment of any fees and deposits, is being done only after the applicant has fully investigated, to its satisfaction, those facts which applicant deems material and necessary to the decision to apply for a rental unit. You authorize AH to verify your information through any means, including consumer-reporting agencies and other rental-housing owners. You acknowledge that you had an opportunity to review our rental-selection criteria, which include reasons your Application may be denied, such as criminal history, credit history, current income, and rental history. You understand that if you do not meet our rental-selection criteria or if you fail to answer any question or give false information, we may reject the Application, retain all application fees as liquidated damages for our time and expense, and terminate your right of occupancy. Giving false information is a serious criminal offense. In lawsuits relating to the Application or Lease, the prevailing party may recover from the non-prevailing party all attorney's fees and litigation costs. We may at any time furnish information to consumer-reporting agencies and other rental-housing owners regarding your performance of your legal obligations, including both favorable and unfavorable information about your compliance with the Lease, the rules, and financial obligations. Fax or electronic signatures are legally binding. We do not sell your information or provide it to third parties for any purpose not directly related to this application.

      Right to review the Lease. Before you submit an Application or pay any fees or deposits, you have the right to review the Application and Lease, as well as any community rules or policies we have. You may also consult an attorney. These documents are binding legal documents when signed. We will not take a particular dwelling off the market until we receive a completed Application and any other required information or monies to rent that dwelling.

      Additional provisions or changes may be made in the Lease if agreed to in writing by all parties. You are entitled to a copy of the Lease when it is fully signed.

      Images on the apartment and/or the Ark House website represent a sample of a unit and may not reflect specific details of any unit. For information not found on our web-site regarding availability, unit characteristics or other questions, please call Ark House at (972) 671-7144.

      THIS APPLICATION IS NOT COMPLETE UNTIL THE LEGIBLE PHOTO ID’S FOR EACH OCCUPANT IS RECEIVED BY ARK HOUSE AT OCCUPANCY@ARKHOUSEDALLAS.ORG OR BY ATTACHMENT TO A TEXT MESSAGE SENT TO (972) 671-7144.

      This Application and the Lease are binding documents when signed. Before submitting an Application or signing a Lease, you may make a copy of these documents to review and/or consult an attorney. Additional provisions or changes may be made in the Lease ONLY if agreed to in writing by all parties.

      PLEASE SIGN IN THIS BOX:

      ======= WHO FILLED OUT THIS FORM? =======

      =======================
      INSTRUCTIONS:
      After reviewing the information entered above and checking the box above, you have completed the application form. Click the "SUBMIT APPLICATION" button to submit the application. Please remember the application is NOT complete until you submit photo ID's by sending via text message to (972) 671-7144. Also, you must complete the credit/debit card authorization.
      =======================

      AFTER SUBMITTING APPLICATION you will be directed to a new page to fill out the "Credit/Debit Card Authorization".


        CREDIT CARD AUTHORIZATION


        PLEASE COMPLETE ALL FIELDS:

        This agreement is between Ark House, the credit card owner, and the applicant(s) for an Ark House apartment.

        The patient or their representative, , certifies that , the cardholder, has authorized Ark House to charge the credit/debit card listed below for $20.00 for the patient's background check. Ark House will pay for the background checks for each of the other applicants listed on the Ark House application. I (person submitting this form) further certify that I have permission from each of the applicants to order the background checks in support of the Ark House occupancy application. Further, it is agreed that the background check fee is NONREFUNDABLE!

        This credit/debit card authorization will also be used to pay for rent if/when the patient and/or occupants take possession of an Ark House apartment. The initial payment will include the security deposit, a partial week consisting of the days leading up to next Friday, and one full week in advance. Future payments will be due on subsequent Friday’s paying in advance for one week’s rent (All rent is due one week in advance).

        You may cancel this authorization at any time by contacting us in writing or by email. This authorization remains in effect until canceled. If canceled, you must vacate the apartment immediately or provide an alternate charge/debit card.

        CREDIT CARD INFORMATION

        Card Type: MasterCardVISADiscoverAMEXDiners ClubDebit Card

        <== 2 digit Month / 2 digit Year

        I was authorized by the credit/debit card owner and ALL persons listed on the Ark House application to permit Ark House to charge the credit card above for and to perform background checks required for Ark House occupancy and for rent payments should the patient and/or other occupants move into the Ark House. I understand that this form will be saved to file for future transactions on this account and for a period of time afterward.

        Sign in the box below

        Signed by:
        Signed by Email:

          ARK HOUSE REFERRER SIGNUP

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            ARK HOUSE VOLUNTEER INTEREST SURVEY

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