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?* Yes No SSN:*Driver's License #:* DOB:* 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?* Yes No Spouse 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?* Yes No How much and when does it come in?* Are you taking any current medications?* Yes No Please list them:* Addictions & TreatmentDo you have any current or former addictions?* Yes No Please explain:*Have you attended rehab?* Yes No Which one?* Duration/Date Completed:* Employment InfoAre 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 HistoryHave 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 & ConsentHow 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:* MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.