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"Extended Stay Registration/Application"

( A separate Registration is required for each Guest)

phone: 215-554-7755/email: ettelegna1@verizon.net

Please complete and submit this form along with the reservation form located on the "Book a room or Event/Policies" Tab/ Page) Please allow 48-72 hours for review and or approval.



FULL NAME*

SOCIAL SECURTY NO*

DOB*

DRIVER'S LICENSE NUMBER*

PHONE NUMBER

EMAIL*

ADDRESS*

WILL YOU REQUIRE ANY SPECIAL ACCOMODATIONS, IF SO, PLEASE EXPLAIN*

VEHICLE INFORMATION: YEAR, MAKE, MODEL, COLOR, PLATE # & STATE REGISTERED*

CURRENT EMPLOYER*

OCCUPATION*

SUPERVISOR NAME AND CONTACT NUMBER

EMPLOYER'S ADDRESS

MONTHLY INCOME*

PERSONAL REFERENCE #1: NAME, RELATIONSHIP, ADDRESS & PHONE NUMBER*

PERSONAL REFERENCE #2: NAME, RELATIONSHIP, ADDRESS & PHONE NUMBER*

HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEAMENOR

Select an option

HAVE YOU EVER BEEN EVICTED

In addition to the above information please provide the following:

·

1) A current government issued Photocopied ID

2) Photocopies of proof of income.

3) Copy of current credit report ( dated within 30 days)

4) Copy of current back ground check ( dated within 30 days)


By completing the requested information above and "sending"/Submitting to Angie's Private Guest Home, you are authorizing the contact of past and present employer and landlords and any other sources deemed necessary to investigate and complete the registration/application process. In addition, by "Sending" this information to Angie's Private Guest Home, you are attesting that all information submitted is true, accurate and complete to the best of your knowledge. 

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