Application Applying For: Men's ResidenceWomen's Residence Today's Date (required) First Name (required) Last Name (required) Date of Birth (required) Date of Sobriety (required) Cell Phone (required) Marital Status Address Your Email (required) Emergency Contact (required) Emergency Number (required) Emergency Address Employer Name Employer Number Employer Address Shifts worked each week List days off Hours worked per week Hourly Wage How are you Paid? WeeklyBi-Weekly Do you have a medical doctor? YesNo Doctor's Name Doctor's Number Other Sober Living residences? Name, Location, Reason for Leaving List all misdemeanor and felony charges with dates Probation Officer's Name Probation Officer's Number Parole Officer's Name Parole Officer's Number Any sexually based offenses? YesNo Any assault charges? YesNo Year, Make and Model of your vehicle Car Color License Plate Number Sponsor's Name Sponsor1's Number I have read, understand, and agree to the house rules YesNo I understand my deposit can be used as my last week's rent if my move out date is planned and approved. I also understand and agree that if I leave unexpectedly, I forfeit my deposit YesNo