Transitional Housing Application

Personal Info

Name*

First Middle Last

Email:*

Phone #:*

Military Veteran?*

Yes
No

SSN:*

Driver's License #:*

DOB:*

Race:*

Gender:*

Most Recent Address:*

Street Address City State ZIP Code

Are You Currently Married?*

Yes
No

Spouse Name:*

Nearest Relative:*

Relation to You:*

City/State:*

Phone # of Nearest Relative:*

Name/Age of people traveling with you:*

How long have you lived in Bay County?*

Your current transportation:*

Reason why you need transitional housing:*

Medical Health

Do you have any medical limitations/disability?*

Do you receive SSI or SS?*

Yes
No

How much and when does it come in?*

Are you taking any current medications?*

Yes
No

Please list them:*

Addictions & Treatment

Do you have any current or former addictions?*

Yes
No

Please explain:*

Have you attended rehab?*

Yes
No

Which one?*

Duration/Date Completed:*

Employment Info

Are you currently employed?*

Yes
No

Why not?*

Your current employer:*

How long have you had this job?*

# of hours per week:*

Supervisor name/phone #:*

Hourly wage:*

What are your work skills?*

Arrest History

Have you ever been arrested?*

Yes
No

Date of last arrest:*

Reason for incarceration:*

Release date:*

Have you ever been charged or convicted of a sexual offense?*

Yes
No

Please explain:*

Have you ever been charged or convicted of a violent crime?*

Yes
No

Please explain:*

Have you ever been convicted of a felony?*

Yes
No

Please explain:*

Are you currently:*

in jail
on probation
on parole
none of the above

Probation officer's name and #:*

Verification & Consent

How did you hear about The Ark?*

Do you currently attend a church?*

Yes
No

Which church?*

Transitional Housing Rules Consent:*

I have read The Ark Transitional Housing Rules thoroughly and I'm in agreement that if I were to move in, they will be enforced.

With my signature below, I verify that the information in this application is true.

Your Signature:*

Enter your full name above.

Today's Date:*

Name

This field is for validation purposes and should be left unchanged.