Humble House Ministries, Inc.
Panama City (850) 640-2022, Humblehouseministriesinc@gmail.com
Tallahassee (850)-999-2490, Humblehousetally@gmail.com
humblehouseministries.org
A faith based, Biblically oriented, addiction recovery ministry
DORM #:
WHERE YOU ARE HOUSED:
Please circle the program you are interested in. During the interview, the staff will determine which program we feel you would better qualify for.
Transitional Housing:
Panama City, FL or Tallahassee, FL
Recovery Program:
Panama City, FL or Tallahassee, FL (Circle One)
For staff only: Interview Date:
-
Month
-
Day
Year
Date
Are you currently in a facility? If so, which one:
DOC#:
EOS Date:
Person on contact at your facility:
Any access code needed to speak to you?
(If you do not fill out this application in its entirety, you will not get an interview.)
CONTACT INFORMATION:
Date:
-
Month
-
Day
Year
Date
Name
First Name
Middle Initial
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Race (Circle One) White, Black, American Indian, Asian, Hawian or Other:
Cell Phone #
Other Phone #
Email
example@example.com
COURT APPEARANCES:
Do you have any upcoming court appearances? Y or N (Circle One)
If yes, please provide:
Date
Location
Reason
Revised 5/6/2025
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Humble House Ministries, Inc.
Panama City (850) 640-2022, Humblehouseministriesinc@gmail.com
Tallahassee (850)-999-2490, Humblehousetally@gmail.com
humblehouseministries.org
A faith based, Biblically oriented, addiction recovery ministry
Judge
Public Defender /Lawyer
Phone #
Public Defender Email:
example@example.com
Additional Notes Regarding Court: (Office use only)
Who do we contact in case of an emergency?
Name
First Name
Last Name
Relationship to you
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone #
Other Phone #
Email
example@example.com
Do you have a Social Security Card? Y or N (Circle One)
Y
N
Social Security #:
Do you have a picture ID? Y or N (Circle One)
Y
N
Type:
Driver's Licence
State
Is License Valid? Y or N (Circle One)
Y
N
RESIDENCY INFORMATION:
Are you recently (last 6 months) released from a correctional facility? Y or N (Circle One)
Y
N
If yes, what facility and how long was your incarceration:
What is your current housing status? (Circle One)
Homeless
Staying with Friend/Relative
Staying in Hotel/Motel
Revised 5/6/2025
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Humble House Ministries, Inc.
Panama City (850) 640-2022, Humblehouseministriesinc@gmail.com
Tallahassee (850)-999-2490, Humblehousetally@gmail.com
humblehouseministries.org
A faith based, Biblically oriented, addiction recovery ministry
Renting Own Home Other:
What is your current living address, if applicable?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
LEGAL STATUS: (Note: A prior criminal history will not necessarily disqualify you)
Have you ever been registered as a sex offender/predator? Y or N (Circle One)
Y
N
Have you ever been charged with child neglect or abuse? Y or N (Circle One)
Y or N
If yes, please explain:
Are currently on probation? Y or N (Circle One) If yes, please provide:
Y
N
Charge/Offense
Probation Start
-
Month
-
Day
Year
Date
Probation Ends
-
Month
-
Day
Year
Date
If not currently on probation, have you been convicted of any felonies within the last 10 years? Y or N (Circle One)
Y
N
If yes, please provide:
Nature of Offense
Date of Conviction
-
Month
-
Day
Year
Date
Sentence Received
Nature of Offense
Date of Conviction
-
Month
-
Day
Year
Date
Sentence Received
Are you, or will you, be required to pay any fines, probation fees, court costs or restitution? Y or N (Circle One)
Y
N
If yes, please state what and how much monthly:
Type
Monthly Amount
Type
Monthly Amount
Revised 5/6/2025
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Humble House Ministries, Inc.
Panama City (850) 640-2022, Humblehouseministriesinc@gmail.com
Tallahassee (850)-999-2490, Humblehousetally@gmail.com
humblehouseministries.org
A faith based, Biblically oriented, addiction recovery ministry
Are you initiating or undergoing any civil proceedings (divorce, child custody, lawsuits, etc.)?
Y or N (Circle One)
If yes, please provide more information:
EMPLOYMENT HISTORY:
What is your current employment status?
Unemployed Working Part Time Working Full Time Self Employed (Circle One)
Please list any trade or professional skills you possess that could be of value to an employer:
Please list your previous three jobs and job duties:
MEDICAL & MENTAL HEALTH HISTORY:
Do you currently have any physical health problems you are dealing with?
Y or N (Circle One)
If yes, please explain:
Have you had any serious illnesses, injuries, or surgeries in the past? Y or N (Circle One)If yes, please state when and what:
Are there any physical limitations as to what jobs you may perform? Y or N (Circle One)If yes, please state what:
Should be Empty: