Application Process – Step 2 Application Form Step 1 of 5 20% Personal InformationApplication Date(Required) MM slash DD slash YYYY Applicant Name(Required) First Last Applicant Sex(Required) Male Female Applicant Birth Date(Required) MM slash DD slash YYYY Applicant AgeApplicant Phone Number (How can we reach you?)(Required)Applicant Social Security NumberDo you have a permanent address?(Required) Yes No If you have a permanent address, please tell us below.Applicant Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Education HistorySchoolCompleted (Yes/No)From (mm/yyyy)To (mm/yyyy) Add Remove(press the + symbol to the right to add another entry)Employment HistoryEmployerPosition/SkillFrom (mm/yyyy)To (mm/yyyy) Add Remove(press the + symbol to the right to add another entry) Family InformationSpouse? No Yes Spouse's Name First Last May We Contact Your Spouse? No Yes Spouse's Phone NumberHow is your relationship with your spouse?Spouse's Address (if different from your address) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Children (if applicable)Child NameChild AgeHow is your relationship with your child? Add Remove(press the + symbol to the right to add another entry) Health InformationRate Your Physical Health(Required) Excellent Average Poor Physical Health CommentsRate Your Mental Health(Required) Excellent Average Poor Mental Health CommentsShort-Term IllnessesIllness Add Remove(press the + symbol to the right to add another entry) Long-Term IllnessesIllness Add Remove(press the + symbol to the right to add another entry)Prescription MedicationsMedications Add Remove(press the + symbol to the right to add another entry) Substance Abuse HistoryAge of first use?(Required)Last time you used?(Required)(mm/dd/yyyy)How often do use?(Required) Daily Weekly Occasionally Recreational Drugs UsedDrug Name Add Remove(press the + symbol to the right to add another entry)Are you facing current criminal charges?(Required) No Yes LawyerJudgeCase WorkerParole OfficerPending ChargesChargeFelony/Misdemeanor?ClassCase #JudgeCourt Date (mm/dd/yyyy)Sentenced (yes/no)Rehab (yes/no) Add Remove(press the + symbol to the right to add another entry)Past ChargesChargeFelony/Misdemeanor?ClassCase #JudgeServed Time (yes/no)From (mm/yyyy)To (mm/yyyy) Add Remove(press the + symbol to the right to add another entry) Faith InformationHave you ever been in a recovery program?(Required) No Yes Was it a faith based recovery program?(Required) No Yes Do you consider yourself a religious person?(Required) No Yes Do you believe in God?(Required) No Yes Do you pray?(Required) Never Occasionally Often Do you read the Bible?(Required) Never Occasionally Often If you were to die tonight, would go to heaven?(Required) Yes No Not Sure Who referred you to FOS?List the reasons why you believe Friends Of Sinners can help you:I certify that the information in this application form is correct.(Required) yes I understand that completion of this application does not guarantee my acceptance into the Friends of Sinners Program.(Required) yes I understand that the Friends of Sinners Fee is $500.00 non-refundable (First Month Rent) and $110.00/ every week afterwards.(Required) yes