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Please mail or fax to:
326 "A" Street, Suite 5B - Boston MA 02210-1722 Fax: (617) 262-5712
First Name________________________________
Last Name________________________________ Sex_______
Address__________________________________________
City___________________________State_____Zip______
Age___
Home Phone: (____)_____________________________
Cell Phone: (____)_____________________________
Work Phone: (____)_____________________________ Ext: ____
FAX Phone: (____)_____________________________
E-Mail: _______________________________________
Please release:
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 Home Phone
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Work Phone
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E-Mail Address
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We must release at least ONE telephone contact number
Occupation_______________________________________
Do you smoke?
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Yes
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No
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Do you have pets?
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Cat
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Dog
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Are you:
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Gay
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Lesbian
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Straight?
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If you are a student, are you an
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Undergrad
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Grad Student
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What school are you attending?__________________________
What are you studying?_____________________
If you have children living with you, please note
their first name(s) and age(s):______________________________
_________________________________________________________
Hobbies & Interests__________________________________________________________
THE FOLLOWING QUESTIONS APPLY TO THE TYPE OF
PERSON YOU WOULD CONSIDER AS A POTENTIAL ROOMMATE.
Please place an "X" beside all situations that you would consider:
MALE
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LESBIAN
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GRADUATE STUDENT
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FEMALE
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DOG OWNER
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COUPLE
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SMOKERS
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CAT OWNER
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PARENT WITH CHILD
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GAY MALE
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UNDERGRADUATE
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PARENT WITH TEENAGER
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Age range preference: _____________________
Have you used The Roommate Connection before?
Yes
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No
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If not, how did you hear about us?
__________________________________________________________
Are you currently living in the unit?
Yes
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No
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If not, when will you be signing a lease? _________
What section of town do you live in? ________________
Intersecting street? ___________________
Total number of:
_____ Bedrooms? _____ Bathrooms? _____ Showers?
Are you walking distance to:
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Bus?_____________ minutes walk
__Local __Express __To Subway
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Subway?_____________ minutes walk
__Red __Orange __Green __Blue __Silver
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Commuter Rail?_____________ minutes walk
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Date available? _______________
Their share of rent? $______________
Is heat included in the rent?
Yes
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No
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How much security deposit would you like? $______________
Do you require last month's rent?
Yes
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No
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How many roommates are you seeking? __________
If you have additional people in your household, please give us information on them:
- First Name___________________ Sex___ Age____ Occupation___________________________
- First Name___________________ Sex___ Age____ Occupation___________________________
Do any of them smoke? _____________
Are any of them students? _______________________
What type of building do you live in?
Apt. Bldg
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Single Family
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2-Family
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3-Family
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What floor(s) is your unit on? _________________
How many levels is your apartment or house? ______
Please circle the amenities your home has to offer:
Room for furniture in common areas
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Hardwood floors
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Exposed brick
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Wall-to-wall carpeting
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Dining room
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Working Fireplace
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Roofdeck
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Eat in kitchen
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Porch
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Balcony
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Laundry
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Deck
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Cable TV
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Dishwasher
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Swimming pool
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Air conditioning
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Jacuzzi
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Tennis courts
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Storage
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Furnished bedroom
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Is there parking?
On Street Parking (no permit)
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Permit Street Parking
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Off Street Parking
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Garage
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Is there an extra charge for parking? If so, how much? $_____/ month.
AGREEMENT
I, the undersigned, engage The Roommate Connection, Inc. of Boston, MA for the following purposes only:
1) To provide me with qualified introductions to persons who desire to share living facilities and expenses with another person.
2) To provide me such service until a suitable roommate is found for a non-refundable fee. I understand that I must stay in touch with the agency at least once every seven (7) days or my account will be closed permanently. Service may be reinstated at the discretion of The Roommate Connection within 30 days of closure for a $10 charge. This account is non-transferable.
The Roommate Connection, Inc. stands behind its placements for a period of sixty (60) days; so that if within a two month adjustment period you find it to be an unworkable situation, we will resume service to you at no additional charge. In order for us to honor this guarantee, you must notify the agency immediately with the name and file number of your new roommate and the date you begin living together. This new roommate must be a client of The Roommate Connection and notification must be made to the agency prior to the date you begin living together. I agree that The Roommate Connection may reveal to persons it considers prospective roommates all of the information, not limited to but including, oral and written material that either I or The Roommate Connection has provided. The privilege and the responsibility of final selection, acceptance or rejection of a potential roommate is to be mine. The Roommate Connection reserves the right to approve or decline any changes made to this account.
In consideration of services rendered by the The Roommate Connection, the rates charged therefore, the client or his or her legal representative agrees to and hereby releases The Roommate Connection and its employees, representatives and agents, successors and assigns, for the negligent or wrongful acts or omissions of its employees, agents or representatives.
I agree that this document embodies and is intended to embody the entire agreement between the undersigned and The Roommate Connection.
NAME_____________________________________________________
DATE________________________________
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BY FAX:
Fax anytime to 617/ 262-5712
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BY MAIL:
The Roommate Connection
326 "A" Street, Suite 5B
Boston MA 02210-1722
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Please send my initial printout by:
Please send my subsequent weekly printouts via:
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$90 Basic Service Fee
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OPTION
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$10 for each additional roommate (after the first)
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You must download Adobe Acrobat Reader if you subscribe to the e-mail option.
I hereby authorize The Roommate Connection, Inc. to charge all applicable service fees to my credit card. I understand the service is valid until I find a suitable roommate, for a non-refundable service fee. I also understand I need to check in at minimum once per week on my assigned check in day, and that my account will be cancelled if I fail to make contact with the agency. Cancelled accounts may be reinstated within 30-days of closure for a $10 charge.
Your Signature:_________________________________________
Date:_________________________________________________
My Credit Card Number is:
_____________ _____________ ____________ ____________ Expires______
Circle one:
MasterCard - VISA - American Express
My FAX number is: (______) _____________________
My EMAIL address is: _______________________________
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Questions? Call us at 617/ 262-5712
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