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Housing Application
First Name
Last Name
Email
Phone
Date of Birth
Place of Birth
Aliases
Current Address (or Last Address)
City
State
Zip
Marital Status
Single
Widowed
Divorced
Married
Separated
Spouse's Name (if married)
Number of Children
How much is your monthly child support payment?
Highest Level of Education
High School
GED
Some College
College
Post-Graduate
Do you receive a check of any kind?
Yes
No
If yes, list how much you are receiving and the reason for receiving funds.
Do you have legal issues or court dates?
Yes
No
If yes, please describe.
Are you on probation or parole?
Yes
No
If yes, please explain.
Payment Amount
How often?
Are you a registered sex offender?
Yes
No
If yes, please describe.
Do you take prescription drugs?
Yes
No
If yes, list medications taken and when.
Do you have (or have you had) any medical conditions that requires doctor's care?
Yes
No
If yes, list all.
Have you ever been in a recovery program?
Yes
No
If yes, please list name of program, location, and dates attended.
What is your addiction?
What is your longest length of time being clean?
Have you accepted Jesus as your personal savior?
Yes
No
If yes, when?
List your skills, including work experience.
What are your talents and hobbies?
Is there anything else you want us to know about you?
How did you hear about us? If a person or organization referred you, please list them.
I certify that the information I provide on this form is true to the best of my knowledge. I also consent to a background check, as well as random drug tests and inspections.
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