Application

Name*

First

Last

Birth Date*

Age

Today’s Date*

Home Phone Number

Cell Phone Number*

Email*

Able to Safely Sleep on Top Bunk?*

Yes

No

Current Address

City/State/Zipcode*

How Long have you been at your current address?

State Number If Applicable

Employer's Name

Income Amount

Employer's Phone Number

Employer's Address

Employer's Address

Street Address

Address Line 2

City

State / Province

ZIP / Postal Code

Country

Empty Space

Length of Employment

Other Income Source(s)

Other Income Amount

Counselor's Name

Counselor's Name

First

Last

Counselor's Email

Additional Information

Do not include any information that could be considered sensitive (SSN, Driver's License #, etc)

ADDICTIONS or DRUGS USED (including alcohol)

EVER CONVICTED OF ANY VIOLENT CRIMES*

Yes

No

ARE YOU ON THE SEX OFFENDER REGISTRY*

Yes

No

DO YOU HAVE ANY PENDING CHARGES OR LITIGATIONS*

Yes

No

HAVE YOU EVER BEEN TO UNITY HOUSE BEFORE*

Yes

No

ARE YOU A VETERAN*

Yes

No

SOBRIETY DATE

SPONSOR’S NAME

HOW LONG

PROBATION OFFICER’S NAME

PH. NUMBER

PRESCRIBED MEDICATIONS

ALLERGIES

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