First Name

Last Name *

Date of Birth *

Gender *

Primary contact number *

Please enter a valid phone number so we can contact you regarding your application.

Have you ever lived in one of our homes, or have you applied in the past?

Yes

No

Desired Move-In Timeline *

What is your current address? *

Please provide your current legal address here. Include the number (apartment # if applicable), street, city state, and zip code. Please note: this may not be the address where you currently live.

Date of Last Use *

Have you been convicted of any felonies? *

Yes

No

Have you ever been found guilty of a sexual offense? *

Yes

No

Have you ever been convicted of arson? *

Yes

No

Are you currently on probation?* *

Yes

No

Are you currently on parole?* *

Yes

No

Have you ever been in residential treatment?

Yes

No

If you are being released from a treatment program, please select from this list. If not, please skip ahead to “Financial Information

Were you in another program previously? (Please select the type of program you last attended)

If you are awaiting a release from jail or graduation from a program, please tell us what that expected date is.

Please describe any and all sources of income which you will use to pay rent *

Please tell us anything that would be helpful for us to know when contacting you.

You might want to note what phone number or email address (personal or caseworker) is the best means of contact.

I hereby authorize RHI and its designated agents to conduct a review of my background including income, housing, treatment, criminal history, or any other public records. I authorize any individual, company, or public agency to release any information, verbal or written, pertaining to me, to RHI or its agents.

Agreed by: *

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