Hospitality Apartments | Security Questionnaire

Security Questionnaire

In order to complete your request for a stay, after you have spoken with the office staff by phone and received your Hospitality Apartments reference number, please fill out and submit the following questionnaire.

Today's Date:

Hospitality Apartments Waiting List Number:

HA-

Patient Name:

Caregiver(s) Name(s):

Name of person filling out this form:

E-mail address:

By making application for an apartment, do you agree to a criminal background check for the patient and caregiver(s)?

Yes

Has the patient or caregiver(s) ever been convicted of a crime of violence, crime of domestic violence, crime against a child, crime of theft, or crime involving illegal drugs?

Yes

Does the patient or caregiver(s) have a civil protection order against him or her?

Yes

Is the patient or caregiver(s) on probation or parole?

Yes

Has the patient or caregiver(s) been required to register on a State or National Sex Offender Registry?

Yes

Requesting a Stay

Checking In