Online Application

Full Name*

First NameLast Name

E-mail*

Phone Number*

Area CodePhone Number

Secondary Contact Phone Number

Area CodePhone Number

Birth Date

MonthDayYear

Gender

Preferred Move in Date

MonthDayYear

Have you ever previously resided in a sober living?

YesNo

If "yes" please list name:

I left my previous sober living for the following reason:

RelapseVoluntarilyOther

Are you currently employed?

YesNo

Current Employer

Length of Employment

Monthly Salary

Are you an alcoholic?

YesNo

Date of your last drink?

Date

Are you addicted to drugs?

YesNo

Date of last drug use?

Date

Please list drugs you have used addictively:

How many 12 step meetings do you attend weekly?

Do you have any prior convictions for any violent or sexual crimes?

YesNo

Please explain:

Do you have pending charges for any violent or sexual crimes?

YesNo

Please explain:

Have you ever been to a treatment facility for alcohol/drug addiction?

YesNo

If "yes" list the dates of treatment:

Do you take prescription drugs?

YesNo

If "yes" list medications and reasons they are prescribed:

Please list any medical information that would be needed in an emergency:

Any other additional relevant information:

By submitting this application you agree: 1) The information provided herein is complete and accurate. Providing incomplete and/or false information could result in the rejection of the application. 2) Submission of this application does not guarantee a room lease, which is reserved only upon signing of a completed lease agreement by all parties. Additionally, no other agreements, either written or oral, are binding on applicant, owner or owner's agents until the completed lease agreement is signed by all parties. 3) Additional information may be required in order to process your application. Our management team will contact you upon receipt of this online application to obtain any additional information necessary to complete the processing of your application.

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Online Lodger Application Form