$98 USD

+ 4.5% (Credit card processing )

One-Time payment

Tax

$0 USD

Total Amount

$102.41 USD

Eugene Place Application

You are completing an application for Eugene Place (Efficiency bed/1bath) by Healthcare Stays. By completing this application you consent to a background check. Application fee and background check are $98 plus creditcard processing fee. You must send a copy of your driver's license and assignment letter.

Name

Phone Number

Country

Address

City

ZIP

State

Date of Birth *

Short bio *

Preferred move-in date: *

Perferred move-out date: *

Additional occupants? *

if there is anyone else traveling with you provide their full name and email.

Are you traveling with a pet? *

If yes, provide pet's name, weight and breed (dog).

Vehicle Information *

Provide your vehicle's year, make, model and license plate

Emergency Contact *

Provide the name, relationship, and phone number of a person we can contact in case of emergency.

ID and verification provided? *

you must email a copy of your assignment letter or military orders along with government ID (Driver's license) front and back to [email protected].

Agency & Recruiter *

Include the Name of your Travel Agency/Military Branch along with your recruiter/command name, email, and phone number.

Work location *

Include the name, city, and state of the company you'll be working for and your title/MOS.

Traveler's Permanent Address *

street, city, state, and zip code of your permanent address.

Card Number

Expiration Date

CVC