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Housing Application
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Chile
China
Christmas Island
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Cook Islands
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Cote d'Ivoire
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Curaçao
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Denmark
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Equatorial Guinea
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Faroe Islands
Fiji
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French Polynesia
Gabon
The Gambia
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Gibraltar
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Greenland
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Guadeloupe
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Guyana
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India
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Kuwait
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Maldives
Mali
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Mayotte
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Mongolia
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Montserrat
Morocco
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eSwatini
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Phone Number
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How old are you ?
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Date of Birth
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Date
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8
What is your gender preference?
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9
What is your SS#
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10
Are you currently working?
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11
If so, Where?
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12
I.D. or D.L. Number
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13
Have you been convicted of a crime other than a misdemeanor ?
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If so explain why?
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Are you currently on Parole ?
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If so explain why
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Are you currently on probation ?
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18
If so explain why?
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Do you have any medical conditions ?
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If so which ones ?
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21
Are you currently on any medications ?
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22
List Medication If any
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23
Are you a client of any organization? ex. (T-Core, Capital Star, TLCS, ETC)
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24
If so, which one?
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25
Have you ever been evicted from your home?
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26
If so, what was the reason?
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27
What is your source of income?
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28
Do you have any emergency contacts?
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29
Name and number
Name
Number
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30
Name and number
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40
Signature
I Understand All of my information will be treated with confidentiality and will only Be shared with authorized persons or agencies.a.An inspection of personal property will be conducted upon initial entry to the home. b.A random room check will be conducted. c.I must attend all house meetings, as well as “One on One” meetings. d.All questions, problems, etc... will be addressed to the house manager. e.Random drug testing will be conducted, if positive, immediate termination from the program. May have option return in fourteen (14) days with Director and peers approval. f.You will be re-tested and you must have negative results. g.I must inform the house manager of my whereabouts at all times. I must supply my schedule to the house manager. h.Smoking is permitted in designated areas only, (per procedural in smoking) i. The house manager will assign chores to me on a weekly basis. j.All phone calls are subjected to House Rules, (per procedural on phone calls) k.Quiet time begins at 10:00 p.m. (Televisions in common areas are to be turned off and all televisions in the bedrooms will be kept at low volume). Lights out no later than 11:00 p.m.( Including all the televisions in the house). Weekend exceptions may be made. l.Curfew is 10:00 pm Sunday-Thursday, 12:00 midnight on Friday-Saturday. The House manager must be notified if you will not be home at least one hour prior to curfew. Doors are locked for the evening after curfew time. You must re-enter the home at 6:00 a.m.the following morning.m.Absolutely no pets of any kind are allowed in or on the premises without express consent from the Director, for health and safety issues. Violation of these rules will result in your loss of that privilege for one week. A second violation will result in a one-month loss of your privilege. A third violation denotes willful non-compliance and will result in immediate termination from the house. We reserve the right to terminate clients from the program at any time and without prior and/or written notice, if the individual has been found in non-compliance with any of the rules and regulations. By signing, I am stating that I fully understand and agree to co-operate with the terms of the rules and regulations.
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