Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Current Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is this a treatment facility? *

Yes

No

Home/Mobile number *

(###)

###

####

Work number

(###)

###

####

Are you an alcoholic? *

Yes

No

If "Yes" above, date of your last drink

MM

DD

YYYY

Are you addicted to drugs? *

Yes

No

If "Yes" above, date of last use

MM

DD

YYYY

Do you want to stop using alcohol and/or addictive drugs?

Yes

No

Have you been convicted of any violent crimes? *

Yes

No

Do you have current legal matters pending? *

Yes

No

Are you a registered sex offender?

Yes

No

Are you emplyed? *

Yes

No

Are you receiving welfare or other non job-related income?

Yes

No

If not employed, will you get a job?

Yes

No

Marital Status *

Married

Never Married

Separated

Divorced

Widowed

Do you have a medical doctor? *

Yes

No

Have you ever been in a treatment facility for alcoholism and/or drug addition? *

Yes

No

Do you take prescription drugs? *

Yes

No

Date of desired move in *

If immediately move-in is desired, select today's date.

MM

DD

YYYY

Have you lived in a Oxford House or structured living program before? *

Yes

No

If "Yes" above, why did you leave?

Relapse

Voluntary

Other reason

Name of contact 1 *

First Name

Last Name

Address for contact 1 *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number for contact 1 *

(###)

###

####

Name of contact 2 *

First Name

Last Name

Address for contact 2 *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number for contact 2 *

(###)

###

####

Name of contact 3 *

First Name

Last Name

Address for contact 3 *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number for contact 3 *

(###)

###

####

Do you agree to the below statement? *

I understand that the Hope House I am applying for requires house residents to prohibit using alcohol and illegal drugs, expels any resident who violates such prohibition, equally share household expenses including monthly lease payment among all residents, and utilize democratic decision making within the group including inclusion in and expulsion from the house. In accepting these terms the applicant understands that these conditions are different than the normal due process afforded by some local landlord-tenant laws.

Yes

No

Do you agree to the below statement? *

I have read all of the material on this application form including the limitations set forth in the above item regarding landlord-tenant laws. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse.

Yes

No

Name of 1st reference *

First Name

Last Name

Address of 1st reference *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number of 1st reference *

(###)

###

####

Name of 2nd reference *

First Name

Last Name

Address of 2nd reference *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number of 2nd reference *

(###)

###

####

Name of 3rd reference *

First Name

Last Name

Address of 3rd reference *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number of 3rd reference *

(###)

###

####