APPLICATION FOR RESIDENCY

APPLICATION FOR RESIDENCY
Faith On Our Site is an equal opportunity transitional housing provider and does not discriminate against otherwise qualified applicants based on race, color, creed, religion, ancestry, age, sexual orientation, marital status, national origin, disability or handicap, or veteran status.
PERSONAL:
Last First Middle*
Previous Address*

Number & Street

Street Address Line 2

City State Zip CodeState / Province

Postal / Zip Code
Personal Email Address*
example@example.com
Phone*
DOB*

MonthDayYear
Date
Social Security*
Do you have a Bank Account?

YesNo
If yes please provide the Bank Name
Have you ever filed for bankruptcy?
If Yes, Date

MonthDayYear
Date
Single, Married or Divorced?*
Do you have any children? If yes, List Names, Ages, Custody Status?
Probation Officer/Referral Source
Phone
Fax
Email
example@example.com
Substance Abuse/Mental Health Treatment History
Dates:

MonthDayYear
Date
Locations:
What has helped you the most in treatment? What has helped you the least?
Who are your primary social supports?
What are your Strengths? *
What are your limitations/barriers?*
Are you over 18 years old?*

NoYes
Do you have a valid Driver’s license/Identification Card?*
Last Date You Drank Alcohol?

MonthDayYear
Date
Last Date you used illegal Drugs?

MonthDayYear
Date
Have you ever shared needles or used IV drugs?
Have you been Tested for HIV and/or HEP C Do you know the results?
***You will need a recent TB skin Test to be admitted to the Program-Please Provide Proof at intake assessment or with Application***
Test Date

MonthDayYear
Date
Result
Do you have a Sponsor?*

YesNo
Are you willing to work with a sponsor?*

YesNo
Are you legally eligible for employment in the United States?*
Do you have any chronic health problems?
Do you have any special diet concerns or needs?
Please Explain if answered Yes
****Current Prescriptions must be included in the application. All applications are subject to an INspect report. Please bring all prescriptions to your intake interview. ****
Please describe medications here including purpose and dosage. Type N/A if not applicable. *
Prescribing Physician:
Phone
Phone
EDUCATION:
High School(s) City/State
College and/or Vocational School(s) City/State
Degree/Diploma(s) Earned
Degree/Diploma(s) Earned
Other Training or Degrees:
School(s)
City/State
School(s)
City/State
Did you enjoy School?
PROFESSIONAL LICENSE OR MEMBERSHIP:
Type of License(s) Held
State of [State Name] License Number
License Expiration Date

MonthDayYear
Date
This application for Faith On Our Site is good for 30 days only. Consideration for the transitional housing program, after 30 days requires a new application.
SKILLS:
Please list additional skills or abilities that you would like to mention:
RECORD OF CONVICTION:

A conviction will not necessarily automatically disqualify you for approval for the transitional housing program. Rather, such factors as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.
During the last 7 years, have you ever been convicted of a crime other than minor traffic offense? If yes, Explain *
Conviction Dates:
Have you had a crime of violence or Sexual Misconduct?*
Do you have any pending criminal charges?*
What programs did you complete while in the Criminal Justice System?
# Probation Sentences
# Probation Sentences
Age of First Arrest
Personal Goal Statement*
EMPLOYMENT: List last employer first, including U.S. Military Service.

May we contact your present employer?
Most recent employer
Address
Telephone
Position
Dates of Employment: From

MonthDayYear
Date
Dates of Employment: To

MonthDayYear
Date
Salary
Supervisor
Department
Duties
FT PT No. of Hrs
Reason for Leaving
Previous Employer
Address
Telephone
Position
Dates of Employment: From

MonthDayYear
Date
Dates of Employment: To

MonthDayYear
Date
Salary
Supervisor
Department
Duties
FT PT No. of Hrs
Reason for Leaving
Previous Employer
Address
Telephone
Position
Dates of Employment: From

MonthDayYear
Date
Dates of Employment: To

MonthDayYear
Date
Salary
Supervisor
Department
Duties
FT PT No. of Hrs
Reason for Leaving
If you wish to describe additional work experience, attach the above information for each position on a separate piece of paper.
Explain any gaps in work history:
Have you ever been discharged or asked to resign from a job?
If yes, explain
APPLICANT'S CERTIFICATION AND AGREEMENT
I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Faith On Our Site to verify their accuracy and to obtain reference information on my work performance. I hereby release Faith On Our Site its successors and/or assigns from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information.

I understand that, if accepted and approved for the transitional housing program, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal.

I understand that should an offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of the participant agreement of the Faith On Our Site program. However, I further understand that neither the policies, rules, regulations of residency or anything said during the intake process shall be deemed to constitute the terms of an implied participant aggreement contract. I understand that any housing program offered is for a set period duration as set forth in the program contract and at will and that either I or Faith On Our Site may terminate my transitional housing limited licensing agreement subject to the terms and conditions of the agreement.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Should be Empty:

APPLICATION FOR RESIDENCY

PERSONAL:

EDUCATION:

Other Training or Degrees:

SKILLS:

RECORD OF CONVICTION:

APPLICANT'S CERTIFICATION AND AGREEMENT