Application for Membership

Print Name (Last, First, Middle) *

Present Address (Street) *

Check if treatment facility

Address *

Address Line 1

City

State

Zip Code

Date of Birth

Month *

Day *

Year *

Phone Where You Can Be Reached

Home *

Work *

Are you an Alcoholic? *

Yes
No

Date of Your Last Drink?

Are you addicted to drugs? *

Yes
No

Date of last drugs use?

List drugs you used addictively:

When did you attend your first AA or NA meeting? *

How many AA/NA meeting do you now attend each week? *

Do you want to stop drinking alcohol and using addictive drugs? *

Yes
No

Are you employed? *

Yes
No

Who is your employer?

Are you getting welfare or other non-job realted income? *

Yes
No

What?

If you do not have a job will you get one? *

Yes
No

What job plans do you have?

What is your monthly net income right now? *

What do you expect your monthly net income to be next month? *

Marital status [Check one] *

Married
Never Married
Separated
Divorced

Do you have a medical doctor? *

Yes
No

List the doctor's name and phone number:

Doctor

Phone Number

Doctor

Phone Number

Doctor

Phone Number

Have you ever been to a treatment facility for alcoholism and /or drug addiction? *

Yes
No

List the treatment provider, phone number and primary counselor, if any.

Do you take prescription drugs? *

Yes
No

List the drugs and reason the drug has been prescribed.

Date of move in? *

Immediately
other

List the date you would want to move in, if accepted, and why the date is in the future rather than immediately.

Date

Reason:

Have you ever lived in a recovery house before? *

Yes
No

Provide the name and location

I left the previous Recovery House for the following reason: [check one]

relapse
voluntarily
other reason(s)

other reason(s)

I, did or do not owe money to the House I left.

Yes
No

Emergency Telephone Numbers [List family doctor, if you have one, + two family members or friends]

Name and Address *

Relationship *

Telephone *

Name and Address

Relationship

Telephone

Name and Address

Relationship

Telephone

I realize that the Transitional home to which I am applying for residency has been established in compliance with the conditions of § 2036 of the Federal Anti-Drug Abuse Act of 1988, P.L. 100-690, as amended, which provides that federal money loaned to stat the house requires the house residents to (A) prohibit all residents from using any alcohol or illegal drugs, (B) expel any resident who violates such prohibition, (C) equally share household expenses including the monthly lease payment, among all residents, and (D) utilize democratic decision making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant excludes himself or herself from the normal due process afforded by local landlord-tenant laws.

Use this space for additional relevant information: *

I have read all of the material on this application form. I have also answered each question honestly and want to achieve confortable recovery from alcoholism and/or drug addiction without relapse.

DATE: *