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Phone: (603) 863-6553 | Fax: (603) 863-4729

Address: 19 Maple Manor Way, Newport, NH 03733

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MM Addendum to Application

Complete this form only after you have filled out our main application. This attachment is designed to meet the requirements of "Screening and Eviction for Drug UAbuse and Other Criminal Activity: Final Rule

Name*
First Last
Email*
Phone*
Have you, or a member of your household, been evicted from federally assisted housing for drug related criminal activity in the past 3 years?*
- Yes
- No
If Yes, Please explain*
Have you, or a member of your household, been convicted of a drug related criminal activity on the premises of federally assisted housing?*
- Yes
- No
If Yes, Please explain:*
Are you, or a member of your household, currently engaged in the illegal use of alcohol and/or drugs?*
- Yes
- No
If yes, explain:*
Are you, or a family member, subject to lifetime registration as a sex offender under a State Registration Program 982.553(a)?*
- Yes
- No
If Yes, Please explain:*
Please Check the Appropriate Response
Are you, or a family member, currently engaged in, or has engaged in during a reasonable time before admission:
Drug-related criminal activity?*
- Yes
- No
Violent criminal activity?*
- Yes
- No
Other criminal activity, which may threaten the health, safety or right to peaceful enjoyment of the premises by other residents or persons residing in the immediate vicinity?*
- Yes
- No
Other criminal activity that would threaten the health or safety of the owner, staff, contractor or subcontractor?*
- Yes
- No
If yes to A, B, C or D above, please explain:
Head of Household*
- Male
- Female
National Origin*
- Black
- White
- Asian
- Native American
- Alaskan Native
- Pacific Islander
Ethnicity*
- Hispanic
- Non-Hispanic
Other Adult member of the household
- Male
- Female
National Origin*
- Black
- White
- Asian
- Native American
- Alaskan Native
- Pacific Islander
Ethnicity*
- Hispanic
- Non-Hispanic
Signature Authorization*
- I agree that I've answered truthfully and to the best of my ability. Clicking on the registration button carries the same weight as signature.
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Name
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Maple Manor Apt. | 19 Maple Manor Way/Office | Newport, NH 03773 | Ph: 603-863-6553 | Fax: 603-863-4729