Application for Admission Order Number This application may be submitted here, or printed and faxed, mailed, or emailed to the Harbor of Hope, attn. Tom Pontow or Brandon Akes. Basic Information First Name * Middle Initial Last Name * Offender ID Date of Birth * Are you a registered sex offender? * Yes No Housing Information Please provide your current mailing address and contact information. Living Arrangement (prior to the Harbor) * I own the property I live in I am renting the property I live in (My name is listed on the formal rental agreement) I am currently living with friends or relatives I am currently living in a shelter or temporary housing Prison, jail, or treatment facility Name of prison, jail, or treatment facility (if applicable) Street Address * City * State * Zip * Primary Phone Number Email Counselor/PO Information Please provide contact information for your counselor or parole officer Counselor / PO Name Counselor / PO Phone Counselor / PO Email Personal Information Citizenship Status * US Citizen Permanent Resident I-155 Refugee Non-Citizen Are you a veteran? Yes No Are you receiving Food Stamps? Yes No Are you on Medicaid? Yes No Do you believe you have a disability? Yes No Family Information Marital Status Single Married Divorced Widowed Domestic Partner Common Law Other Number of children Medical Information Have you participated in a chemical dependency treatment program? Yes No Have you ever seen a mental health therapist? Yes No Are you currently on any medication? Yes No Have you ever been to AA/NA Yes No Education & Employment Information What is the highest level of education you have attained? Did not graduate High School Diploma GED Technical/Trade School Some College 2 Year Associates Degree 4 Year BA/BS Degree Masters of Graduate Degree Employment History Job 1 - Current or most recent job Company Name Start Date End Date Reason for leaving (if applicable) Status Full Time Part Time Did/Does this job provide benefits Yes No Is/Was this employment through a temp agency? Yes No Average Weekly Pay Position and Job Duties Please provide your job title, as well as some description of your duties and experiences in this position. Employment History, cont. Please briefly describe any previous employment experience. Job 2 Company Name Start Date End Date Position and Job Duties Please provide your job title, as well as some description of your duties and experiences in this position. Job 3 Company Name Start Date End Date Position and Job Duties Please provide your job title, as well as some description of your duties and experiences in this position. Additional Documents If you are a counselor at a prison, jail, or treatment center applying on behalf of a client, please upload the following attachments to submit with the application: Client’s most recent physical Client’s behavior report Personal letter written by the client (outlining current situation and plans for recovery) If you are not in treatment, jail, or prison and wish to apply for residency, please attach a personal letter to be submitted with the application. Upload Files Select Files Rules & Rental Agreement Click the following links to view the House Rules, Client Rules, and Rental Agreement. These links should open in a new tab/window, and you should not lose your place on this form. House Rules Client Rules Rental Agreement Please check the box to acknowledge that you have read and acknowledge the rules and rental agreement. * I have read the rules and rental agreement I verify that all information provided in this application is true and complete. I understand that any falsification or omission may result in this application being denied from the Harbor of Hope.
