* Required Information
Full Name
*
Date of Birth
*
Sex
*
Male
Female
Social Security Number
*
Are you currently homeless?
*
Yes
No
Current Address
Street
*
City
*
Zip
*
Telephone Numbers
Home
Work
Cell
Are you a recovering:
Alcholic
Drugs Addict
Sobriety Date
Drugs of Choice & Last Use
1st
2nd
3rd
Are you currently in a self-help program, i.e AA, NA
Yes
No
Name of Program(s)
How many meetings do you attend per week
Do you have a Sponsor?
Yes
No
Other Recovery Support
Other Recovery Support
Are you currently in inpatient or residential Treatment program?
Yes
No
If so, name of program
Program Case Manager Name
Telephone Number
Whats is your discharge date?
Are you currently on Probation or Parole?
Yes
No
Officer Name
Do you have Health Isurance?
Yes
No
Insurance Name
Policy Number
Have you ever been charged or convicted of any sex crimes?
Yes
No
What State
Please select state.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
List present and previous felony convictions and date of end of sentence
Date
Charge
Sentence
Eos Date
Date
Charge
Sentence
Eos Date
What is your source of Income?
Employment
Disability Payment
Monthly Payment
Employer's Name
Employer's Address
Employer's Phone
Job Title
Weekly Net Income
Length of employment
What is your marital status?
Single
Married
Separated
Divorced
Do you have children?
Yes
No
How many children
Do you take any prescription medications?
Yes
No
What Medications
List names and telephone number of two people who may be contacted in care of emergency
Name
Telephone Number
Relationship
Name
Telephone Number
Relationship
By signing below I certify that the information contained in this application is true, that I understand and accept the conditions set forth above for residency in Prosperity House and that I agree to abide by said conditions should I be voted in as a resident of this house.
Date
Signature
Clear