Soteria House Residency Application

Soteria House Residency Application

Please fill out your information below.
DOC #*
SSN*
Applicant Name*

First NameMiddle NameLast Name
Projected Release Date*

MonthDayYear
Birth Date*

MonthDayYear
Last Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Address*

Current Institution

Street Address

CityState / Province

Postal / Zip Code
Place of Birth*
Age*
Race
Gender
Marital Status*
Spouse's Name

First NameLast Name
Location of Children
Ages of Children
# Boys
# Girls
Education Level*
Religious Affiliation
List N/A if Not Applicable
Health Conditions*
List N/A if Not Applicable
Current Medications*
List N/A if Not Applicable
History of Dependencies (Drug/Alcohol/Inhalants/Other)*
List N/A if Not Applicable
Current Use/Treatment*
List N/A if Not Applicable
Reason for Applying for Residency:*
Name 3 Dangerous Locations for You:*
Employment History*
Other Special Training & Skills
List Current Assets*
List N/A if Not Applicable
List Current Debt*
List N/A if Not Applicable

Military Service

If you did not serve in the military, please proceed to Page 5.
Military Service Start Date

MonthDayYear
Military Service End Date

MonthDayYear
Branch:
Type of Discharge:

References

A family member and a close friend who knows you well enough to comment on your honesty and integrity:
Reference 1 - Name*

First NameLast Name
Reference 1 - Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 1 - Phone Number*

Area CodePhone Number
Reference 1 - Relationship*
Reference 2 - Name*

First NameLast Name
Reference 2 - Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 2 - Phone Number*

Area CodePhone Number
Reference 2 - Relationship*

Essay
Write a one-page essay about yourself, short term and long term goals.*
Signature

All statements above are true to the best of my knowledge, and I understand that any false statements will result in automatic denial.
E-Signature*

Clear
Signature - Date*

MonthDayYear
Date
***************

FOR OFFICE USE ONLY:
________________________________ Approve / Disapprove
Staff Signature
________________________________ Approve / Disapprove
Program Manager / Program Assistant Signature
________________________________ Approve / Disapprove
CEO Signature