Applicants Name Birthdate Social Security Number Recent Address City State Zip Drivers License ICE Name Address Phone Faith Are you disabled? Yes or No? YesNo Do you need medical care? Yes or No? YesNo Do you receive financial assistance from any person or agency? Yes or No? YesNo If so what agency? Are you employed? Yes or No? YesNo If so where? How often are you paid What shift do you work? FirstSecondThird Are you married, single, divorced, or separated? ---SingleMarriedDivorcedSeparated Do you have any addictions? (e.g Drugs, Alcohol, Tobacco, or etc.) When is the last time you have used drugs and/or alcohol? Are you taking any prescribed medications and if so what? Do you have any outstanding warrants? Yes or No? YesNo Are you on probation or parole Yes or No? YesNo Are you a sex offender? Yes or No? YesNo Have you been convicted of any violent crimes? Yes or No? YesNo Why are you interested in living at Project Scope? Please be advised that you are under no obligation to live here unless you have been released to our custody through the judicial court system. PROJECT SCOPE is a non-profit recovery empowering, transitional housing to provide an opportunity to men to reenter the community with the necessary tools to succeed. We are not government funded, but rely on donations, grants, and residents housing fees to make our services available. All of this information has been fully explained and I agree to all the contents. Please return application to: PROJECT SCOPE 1333 West Lusher Ave. Elkhart, Indiana 46517, or [email protected] TEL: 574-333-2949 WEBSITE: projectscope1333.org Signature Δ
