Secure Organization Building Educational Recovery

APPLICATION FOR RESIDENCE for S.O.B.E.R. HOUSE and WOMEN’S PLACE
Please read the Criteria for admissions under the CRITERIA tab on home page before completing this form.

Name: Date: Date of Birth:

Address at Present:

Phone Number:

Sobriety Date:

Marital Status: M S D Sep Number of Children:

Wife's Name:

Children's Names and Ages:

Where do they live:

Do you pay child support: YES NO If YES, amount:

Do you pay alimony: YES NO If YES, amount:

Are You Current Employed: YES NO If yes, provide the following information:

Employer: Phone #:

Length of Employment: Salary:

Are you disabled: YES NO If yes, can you do service work: YES NO

Are you on Probation: YES NO If yes, provide the following:

Probation officer’s name:

Reason you are on probation:

Past legal history:

Have you been convicted of Assault: YES NO If yes, Explain:

Emergency contact person’s name:

Relationship: Phone Number:

Are there any special circumstances we should consider when reviewing your application? YES NO

If yes explain:

I, the undersigned, understand giving any false information in this application may result in the denial of admission into the S.O.B.E.R Home.

ELECTRONIC SIGNATURE:
By typing my name in the box below, I am legally signing my name and attesting to the information in this application.

Applicant’s Signature: Date: