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Are you applying for yourself or a loved one? *MyselfLoved One

Name *

Relationship *

Phone Number *

Email Address *

Applicant's Personal Information

Applicant's Name *

Social Security #

AIS #

Date of Birth *

State Born In *

Gender *

Marital Status *

Race *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Two References With Contact Methods

Name *

Relationship *

Phone Number *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Name *

Relationship *

Phone Number *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Background Information

Religious Affiliation *

Highest Level of Education

Name of Institution *

Should the opportunity come up would you like to get your GED?

Legal Information

Have you ever been convicted of a sexual offense or currently have pending charges? *

Have you ever been to jail or prison? *

Are you currently incarcerated? *

If you answered yes above, please explain your current situation, including charges, dates, judges, etc. *0 / 180

Are you required by a court official, judgment or parole board to complete a live-in treatment program? *

Are you presently on or will you be on? *ParoleProbationCommunity CorrectionsTASCCourt ReferralCommunity ServiceNone

If any are selected, what city or county?

Do you have any pending cases or charges? *

If you answered yes, list them below. Please include charge, court date, county, attorney, and judge.

Do you have problems with or been diagnosed with any of the following conditions? (check all that apply) *High/Low Blood PressureDiabetesHeart ConditionOpen SoresEpilepsyHIV/AIDSHepatitis CTuberculosisBack ProblemsJoint ReplacementMental IllnessVenereal DiseaseOtherNone of These

If you marked other, what is the condition that you have?

Have you ever been under psychiatric care? *

If yes, when?

Diagnosis:

Are you allergic to any food or medications? *

If yes, please list below

Do you have problems with any of the following? *DepressionBipolar DisorderBorderline Personality DisorderAntisocial Personality DisorderBrain InjuryDementiaParanoiaSchizophreniaPsychotic DisorderOtherNone

If other, please explain:

If Yes, please list your medications below. Include be Medication, Dosage, How Often, Date Prescribed, and Reason.

Are you disabled or handicapped to the point that you will be unable to stand on your feet for eight hours a day for volunteer-related tasks? *

Do you receive SSI, Disability or any other Monthly entitlement? *

Substance Abuse/Rehab History

Primary Drug Of Choice:

Secondary Drug Of Choice:

Do you have problems with any of the following?AdderallAlcoholBarbituatesBath SaltsCocaineCrackDilaudidDXMEcstacyGHBHeroinHydrocodoneInhalantsKlonopinLSDLubrimMarijuanaMethMethadoneMorphineOpiatesPsychotropicsRoxicetSpiceValumXanax

Have you previously attended any substance abuse programs? *

If Yes, please list the program names, dates you attended, if you completed, and the circumstances of your departure for each program.

Work History/Job Skills

Do you have experience in any of the following professions: (check all that apply)LandscapingAdministrationAsphalt LaborCarpentryCookingDraftingDrywall FinishingElectricalFlaggingFramingFlooringHeavy Equipment OperatingMechanicPlumbingRetailSalesTelemarketingWelding

List The Places You Have Worked, Date Started, Date Left, Why You Left, and Your Supervisor's Name and Number:

Do you have a valid Driver's License? *

Do you have a CDL? *

Have you had an accident in the last 5 years? *

If yes, was it your fault?

Have you had a DUI in the past 10 years? *

If yes, how many?

Are you a veteran? *

If yes, how many years of service?

If yes, what branch?

Additional Comments

By typing my name, I agree that all the information provided is correct to the best of my knowledge. *

Date *

If applicable Please include copies of Time Sheet, Parole consideration date and any certificates you feel might be pertinent for this application process.

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