APPLICATION FOR RESIDENCY Name First Last 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 Date of birth GenderMaleFemaleEmail Phone NumberEMPLOYMENT INFORMATION:Do you have a job?YesNoType of JobPart TimeFull TimeIf yes, Who is your employer?If No, What are you doing?If you are unable to pay for any reason, who can and/or will you be able to pay your weekly fee?:Name & relationshipLEGAL HISTORY:Do you have any pending criminal charges?YesNoIf yes, please list Are you currently on probation or parole?YesNoProbation/parole officer’s name & which courtHow long on probation or parole?What is your current offense and status?Have you ever been convicted of arson?:YesNoHave you ever been convicted of a sexual assault?:YesNoMEDICAL INFORMATION::Do You Have Any Medical Conditions?:YesNoIf Yes, Please List All Medical Conditions Are u taking any current prescribes medications?:YesNoIf yes, please list medication/dose/reason for taking: SUBSTANCE ABUSE INFORMATION:Primary substance of abuse Alcohol Herion Opiates Oxycontin Cocaine Benzodiazepines Marijuana Other When was your last drink? (mm/dd/yyyy) MM DD YYYY When was your last drug use? (mm/dd/yyyy) MM DD YYYY RECOVERY INFORMATION: How many days/months have you been sober?Are you coming from a treatment program/sober house?YesNoIf yes, name of programHow long were you there?Why did you leave?Do you currently have a sponsor?YesNoAre you working or willing to work the 12 steps?YesNoAre you currently attending any AA or NA meetings?YesNoIf accepted, what is your anticipated move-in date? (mm/dd/yyyy) MM DD YYYY How did you hear about us?AFFIRMATION: I affirm that my answers and information provided by me in this application are true and accurate. In order to process my application, I give Sober Crossings consent to verify the information I provided as needed. I understand that if I am accepted, any misinformation and/or dishonest answers that were given may be grounds for my dismissal. This information is confidential and only for internal use by Sober Crossings.Type full name in boxCAPTCHA