Synergy Transitional Housing Inc - Approved Housing Provider Application

Provider & Contact Information

Provider / Facility Name

Enter exactly as it appears in your records and marketing.

Legal Owner or Company Name

As shown on tax records or legal documents.

Primary Contact

First Name

Last Name

Role / Title

Phone

Email

Website

Housing Information

Organization

Main Property Address

Enter the main property address that will be used for Synergy participants. If you operate multiple houses, list the primary address here and provide details on others in the comments section.

Street Address

City

State

Postal Code

Country

AZDHS Licensing & Sober Living Information

Are you a licensed sober living home with AZDHS?

Yes No

AZDHS Licensing Number

License Expiration Date

Number of beds you would like to offer to Synergy participants Monthly bed rate or rent range Security deposit amount and terms Which utilities are included?

Electric Gas Water Trash Internet/Wi-Fi None

Do you accept third-party payments from agencies/nonprofits?

Yes No

Which programs are you willing to accept?

AHCCCS Housing Programs (AHP, etc.) CoC program payments (including GEO CoC and similar programs) Rapid Re-Housing / PSH rental assistance Other program payments

Preferred payment method

ACH Check Other

Insurance & Compliance

Do you have current homeowner’s/landlord liability insurance on this property?

Yes No

If yes, please upload your insurance declaration or certificate in the document upload section below.

In the past 10 years, has any state or federal agency suspended, revoked, or fined any license related to this housing operation or your business?

Yes No

Allow Synergy staff check-ins and visits with reasonable notice?

Yes No

Required Document Uploads

Please upload clear copies of the following documents. If you are unable to upload, you may email them separately to Synergy Transitional Housing Inc with your facility name in the subject line.

Current AZDHS sober living license

Must show facility name, license number, and expiration date.

Proof of active homeowner’s or landlord liability insurance

Certificate of insurance or policy declaration page.

Letters or notices related to past license actions (if applicable) Sample lease or house agreement used with residents Additional comments or details (optional)

Consent & Electronic Signature

By checking the box and signing below, you certify that the information in this application is true and complete. Synergy Transitional Housing Inc, a 501(c)(3) nonprofit organization, may verify this information, including licensing and compliance history, and approval is not guaranteed.

Transactional message consent

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications, among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Marketing & promotional message consent (optional)

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, and new product or service updates. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Authorized Representative Name

Title

Electronic Signature (type full name)

Date

Become an Approved Housing Provider

Before you start

Provider & Contact Information

Primary Contact

Housing Information

Main Property Address

AZDHS Licensing & Sober Living Information

Insurance & Compliance

Required Document Uploads

Consent & Electronic Signature