Application For Membership In Oxford House

To be accepted in an Oxford House an applicant must complete this application and be interviewed by the residents of the particular Oxford House to which the applicant is applying. The residents of the house then cote on acceptance. An 80% affirmative vote is needed to be accepted. Carefully read the application and honestly answer the questions. Living in an Oxford House is special and if you understand its value it can help you achieve comfortable sobriety without relapse.

1. Name

First NameMiddle InitialLast Name

3. Date of Birth

MonthDayYear

2. Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Check if Current Address is a Treatment Facility

4. Phone Where You Can Be Reached

Format: (000) 000-0000.

5. Are you an Alcoholic?

6. Date of Your Last Drink?

7. Are you addicted to drugs?

8. Date of Last Drug Use?

Date

9. List drugs you used addictively:

10. When did you attend your first AA or NA meeting?

11. How many AA/NA meetings so you now attend each week?

12. Do you want to stop drinking alcohol and using addictive drugs?

13. Are you employed?

(If employed who is your employer?)

14. Are you receiving non-job related income?

(if "receiving non-job related income", What?)

15. If you do not have a job, will you get one?

(if "yes" what job plans do you have?)

16. What is your monthly income right now?

17. What do you expect your monthly income to be next month?

18. Marital Status (Check One)

19. Do you have a medical doctor?

(if "yes" list the doctor's name and phone number)

20. Have you ever been to a treatment facility for alcoholism and/or drug addiction?

(if "yes" list the treatment provider, phone number, and primary counselor; if any)

21. Do you take prescription drugs?

(if "yes" list all drugs and reason each drug has been prescribed)

Have you ever been convicted of a sexual offense?

Are you on the sexual offender registry?

Date of Move In:

Date

Other (if accepted, and date is in the future rather than immediately, Why?)

23. Have you ever lived in an Oxford House before?

(if “yes” provide the name and location of the Oxford House and answer question 24.)

I left the Previous Oxford House for the following reason: (Check One)

Other

I, did or did not owe money to the Oxford House I left.

If I did owe money to the Oxford House I left, I will agree to repay the money I owed to my former Oxford House.

25. Emergency Telephone Numbers. (List family doctor, if you have one, and two family members or friends)

Rows	Relationship	Telephone
1-
2-
3-

26. I realize that the Oxford house to which I am applying for residency has been established in compliance with the conditions of §2036 of the Federal Anti-Drug Abuse Act of 1988, P.L. 100-690, as amended, which provides that federal money loaned to start the house requires that house residents to (A) prohibit all residents from using any alcohol or illegal drugs, (B) expel any resident who violates such prohibition, (C) equally share of household expenses including the monthly lease payment, among all residents, and (D) utilize democratic decision making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant excludes himself or herself from the normal due process afforded by local landlord-tenant laws.

27. Use this space for additional relevant information:

28. I have read all of the material on this application form including the limitations set forth in item 26. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse.

SIGNATURE:

Complete Application. You will be contacted for your interview. 341 8th Street South ● Wisconsin Rapids WI 54494 ● 715-213-1050

Revised Dec 2019

Application For Membership In Oxford House

24. (Answer this question if the answer to question 23 was "yes")