Application for Membership Fishers of Men Ministries

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Mariah Day
10 years ago
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1 Application for Membership Fishers of Men Ministries Date Interviewer 1. Print Name (Last, First, Middle) 2. Date of Birth,, Month Day Year 3. What is your social security number? 4. What is your driver s license number? 5. Present address City State Zip Check here if treatment facility [ ] 6. Phone Where You Can Be Reached Cell ( ) - Work ( ) - 7. Are you an Alcoholic? 8. Date of your last drink? 9. Are you a drug addict? 10. Date of last drug use? 10. Are you on probation or parole? 11. Do you have any wants or warrants? 12. Are you a registered sex- offender? 13. Are you presently registered? 14. What was your last criminal charge, if any? State? Year? 15. Do you have any communicable diseases?

Phone Where You Can Be Reached Cell ( ) - Work ( ) - 7. Are you an Alcoholic? 8. Date of your last drink? 9. Are you a drug addict? 10. Date of last drug use? 10. Are you on probation or parole?

2 What are they? 16. Do you have a history of mental problems? Explain them? 17. Do you have a history of violence? Explain? 18. List drugs you use addictively: 19. Do you attend self- help meetings? Explain? 20. How many meetings do you now attend each week? 21. Do you want to stop drinking alcohol and using addictive drugs? 22. Do you attend church? 23. Are you employed? If yes who is your employer? 24. Are you getting welfare, link card or other non- job related income? If yes what? 25. If you do not have a job, will you get one? 26. What is your monthly income right now? $ 27. What do you expect your monthly income to be next month?

Do you want to stop drinking alcohol and using addictive drugs? 22. Do you attend church? 23. Are you employed? If yes who is your employer? 24.

3 $ 28. Marital status [Circle One] Married> Never Married> Separated> Divorced> 29. Do you have a medical doctor? If yes list the doctor s name and phone number. 30. Have you ever been to a treatment facility for alcoholism and/or drug addiction? If yes list the treatment provider, phone number and primary counselor, if any. 31. Do you take prescription drugs? If yes list drugs and reason the drug has been prescribed. 32. Date of move in? [Circle one] Immediately Other If 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: 33. Have you ever lived at a Fishers of Men house before? If yes, provide the address of the house and answer question # I left the previous Fishers of Men house for the following reason: [check one]

If yes list drugs and reason the drug has been prescribed. 32. Date of move in?

4 Relapsed Voluntarily Removed Other If Other, explain I owed money to the Fishers of Men when I left? If I do owe money to The Fishers of Men when I left, I will agree to repay the money I owe to The Fishers of Men. I owe $ to the fishers of men. 35. Emergency Telephone Numbers. At least ONE is mandatory! [List family doctor, if you have one, + two family members or friends> city, state, & phone number] Are you ordered to pay child support? If yes, what are your monthly support payments $ Are you in arrears? If you are in arrears, how much? 37. Do you have fines in this state or any other state which you have been ordered to pay? If yes, what are they, and what do you owe? 38. I realize that the Fishers of Men Ministries, LLC, 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 , as amended. Which 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

At least ONE is mandatory! [List family doctor, if you have one, + two family members or friends> city, state, & phone number] 1. 2. 3. 36. Are you ordered to pay child support?

5 including inclusion in and expulsion from the group. In accepting these terms, the applicant understands that 2036 conditions are different than the normal due process afforded by some local landlord- tenant laws. 39. I have read all of the material on this application form including the limitations set forth in item 28. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse. Furthermore, I have read and agree to the terms of the Fishers of Men handbook and will carry those requirements out to the best of my ability. SIGNATURE: DATE: FOR USE BY Fishers of Men Ministries, LLC ACCEPTED NOT ACCEPTED MOVE IN DATE MOVE OUT DATE: HOUSE KEYS RETURNED YES NO OUTSTANDING DEBT TO HOUSE $ DATE REPAID

I have read all of the material on this application form including the limitations set forth in item 28.

6 2013 Fishers of Men Ministries, LLC Call or for The Fishers of Men

Name Date of Birth (Last) (First) (Middle initial) Address City. State Zip County Drivers Lic/ID. Home Telephone Cell Work.

Christian Community Action 200 S. Mill Street, Lewisville, TX 75057 972-436-HELP www.ccahelps.org Please Print Name as it appears on picture ID. Today s Date Name Date of Birth (Last) (First) (Middle initial)