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KAWERAK, INC. ~ Education, Employment, and Training Division
P.O. Box 948, Nome, AK 99762 ~Web site: www.kawerak.org ~Phone (907) 443-4358 ~1-800-450-4341 ~Fax: (907) 443-4485
LANDLORD VERIFICATION FORM
Name: __________________________________,__________________________________________________
(Last) (First) (Middle Initial)
Social Security Number: - - Date - -
I hereby authorize the following organization to release information concerning my employment status.
____________________________________________ _________________________
Signature of Applicant Date
__________________________________________________________________________________________
TO BE COMPLETED BY LANDLORD OR RENTAL OFFICE:
The above named individual has applied for services through the Kawerak, Inc. Education, Employment
and Training Division. Please provide the following information for verification:
Landlord Name : ________________________________________________________________________
Landlord Address: ______________________________________________________________________
Phone Number: ___________________________ Fax number:____________________________
Email Address: _______________________________________________
Name(s) on the lease:____________________________________________________________________
Beginning Lease Date:______________________ End of Lease Date: ______________________
Cost of Deposit: ____________________ Monthly Rent:__________________________
Make Check Payable to:
_____________________________________
Address _____________________________________
_____________________________________
_____________________________________
SIGNATURE OF LANDLORG OR RENTAL OFFICE DATE