Sober living facility for men in the Mid-Ohio Valley

Name *

First Name

Last Name

Date of birth *

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Your best phone number *

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Current Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Previous Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact number for previous landlord *

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Status *

Please check the box for all that apply:

I am currently on parole

I am currently on probation

None of the above

Have you been convicted of any felonies or misdemeanors? *

Yes

No

Are you a registered sex offender? *

Yes

No

Have you ever been convicted of a violent crime? *

Yes

No

Do you currently have a job? *

Yes

No

Phone Number

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Start Date

MM

DD

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End Date

MM

DD

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Phone Number

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Start Date

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DD

YYYY

End Date

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DD

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Are you receiving public assistance or any non-job related income? *

Yes

No

Do you pay child support? *

Yes

No

Are you in arrears in child support? *

Yes

No

Have you completed a treatment program of at least 28 days? *

Yes

No

Do you have at least two forms of proper ID? *

Yes

No

I understand that rent is collected on the first day of each month. *

Yes

Today's Date *

MM

DD

YYYY