| Today's Date: * |
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| Full Name: * |
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| Current Address: * |
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| Phone Number: * |
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| Email Address: * |
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| Emergency Contact Name & Number: * |
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| Are you currently in school, employed or, volunteering? Please give details: * |
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| If you are incapable of working, please explain: * |
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| A non-refundable $100 administrative fee is mandatory in order to process your application. This fee is necessary to reserve your bed. INITIAL HERE: * |
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| I ensure that all information included on this application is true and that I have not withheld any information from My Brother’z House that will affect my application to their Independent Sober Living Facility. I understand that this application is not a rental agreement, and my signature on this form does not ensure my acceptance into the facility. INITIAL HERE: * |
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| Anticipated move in date: * |
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| How did you hear about us?: * |
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