Resident Application
**All fields required
Today's Date
Date of Birth
Social Security Number
Last Name
First Name
Middle Initial
Current Address
Phone Number
Social worker/case manager/ sponsor
and phone #
How did you find us?
Phone Number
Emergency Contact Name
Are you currently employed, in
school, or volunteering? If yes,
please explain.
If you are incapable of working,
please explain:
A non-refundable $100 administrative fee is mandatory in order to process your application. This fee is
necessary to reserve your bed. This fee will also cover all charges for Resident's keys.
INITIAL HERE:
My Brother’z House requires a 90-day minimum stay for all incoming guest residents.
INITIAL HERE:
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:
Anticipated move in date
Thank you for your interest.
We will contact you upon receipt.