Transitional Housing Application Please fill out and submit the application below. Be sure to review the Transitional Housing Rules before submitting. Personal InfoName* First Middle Last Email:* Phone #:*Military Veteran?*YesNoSSN:*Driver's License #:*DOB:* Date Format: MM slash DD slash YYYY Race:*Gender:*Most Recent Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are You Currently Married?*YesNoSpouse Name:*Nearest Relative:*Relation to You:*City/State:*Phone #:*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 HealthDo you have any medical limitations/disability?*Do you receive SSI or SS?*YesNoHow much and when does it come in?*Are you taking any current medications?*YesNoPlease list them:*Addictions & TreatmentDo you have any current or former addictions?*YesNoPlease explain:*Have you attended rehab?*YesNoWhich one?*Duration/Date Completed:*Employment InfoAre you currently employed?*YesNoWhy 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 HistoryHave you ever been arrested?*YesNoDate of last arrest:*Reason for incarceration:*Release date:*Have you ever been charged or convicted of a sexual offense?*YesNoPlease explain:*Have you ever been charged or convicted of a violent crime?*YesNoPlease explain:*Have you ever been convicted of a felony?*YesNoPlease explain:*Are you currently:*in jailon probationon parolenone of the aboveProbation officer's name and #:*Verification & ConsentHow did you hear about The Ark?*Do you currently attend a church?*YesNoWhich 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:* Date Format: MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.