Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is this address a treatment facility? *

Yes

No

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

Yes

No

Do you use alcohol? *

Yes

No

Do you use drugs? *

Yes

No

Do you want to stop using alcohol / drugs? *

Yes

No

Do you attend any recovery meetings? *

Yes

No

Do you have any current pending legal matters? *

Yes

No

Are you a registered sex offender? *

Yes

No

Are you employed? *

Yes

No

Are you willing to get a job? *

Yes

No

Do you receive welfare or other non-job-related income? *

Yes

No

Do you receive food stamps? *

Yes

No

Marital status *

Married

Never married

Separated

Divorced

Widowed

Do you have a medical doctor? *

Yes

No

Do you take any prescription drugs? *

Yes

No

Desired move in date? *

Immediately

Other

Have you ever lived in an Oxford house or structured living program before? *

Yes

No

I understand that the Exodus House I am applying for requires house residents to prohibit using alcohol and illegal drugs, expels any resident who violates such prohibition, requires residents participation in the financial stewardship program with case management and requires all residents to pay 30 % of weekly income for the household expenses. In accepting these terms, the applicant understands that these conditions are different from the normal due process afforded by some local landlord-tenant laws. I have read all the material on this application form including the limitations set forth in the above item regarding landlord-tenant law. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and / or drug addiction without relapse. *

I agree to these terms

I do not agree to these terms