Name *

First Name

Last Name

Date of Application *

MM

DD

YYYY

Phone *

(###)

###

####

Are you a registered sex-offender? *

Yes

No

What is your desired move in date? *

MM

DD

YYYY

What is your marital status? *

Married

Divorced

Separated

Single

Widower

Do you have children? *

Yes

No

If yes, do you have visitation? *

Yes

No

Do you have a valid Driver's Licence? *

Yes

No

Do you own a vehicle? *

Yes

No

Are you on prescribed drugs? *

Yes

No

One of the requirements of the house is to work at least 30 hours per week. Will you comply? *

Yes

No

Are you willing to attend church at Real Life Ministries with our group on Sundays, and our faith-based recovery meetings on Thursdays? *

Yes

No

Are you willing to have weekly house meetings to iron out any hard feelings or differences? *

Yes

No