FORMTEXT, FORMTEXTFORMTEXT

ProgramApplication

Completing this application may take up to one hour. It can be completed either in Microsoft Word, or handwritten in blue or black ink. The information you provide in this application will be held in strict confidence. We do not share applicant information with ANY law enforcement or correctional agency. Applications may only be submitted in-person at a Defy Ventures information session. You will be notified shortly about when upcoming information sessions will be held.

I submit this application in consideration for the Defy Ventures training and career placement program. I certify that:

  • The information submitted in this application is true and complete. I understand that Defy staff will verify the information I provide here through a rigorous background check.
  • I am willing to discuss all of the information in this application with Defy staff, including my criminal history.

Signature / Date
Print Full Name

GENERAL

If you are completing this application by hand, please print your responses neatly using blue or black ink.

First Name: / Middle Name: / Last Name:
Date of Birth (mm/dd/yy): / Age: / Gender: / Male / Female
Address: / City: / State: / Zip:
Home Phone: / Work Phone: / Cell Phone:
Email:

What type of housing is your current address? (Check one)

Owned apartment / house / Halfway house / Transitional Facility (please name):
Rented apartment / house / Re-entry program housing (please name):
Rented public housing / Homeless shelter
3/4 Housing / Other (please name):
When did you move to this address?(mm/dd/yyyy)

If you are living with other people, what is your relationship to those people?

Check applicable boxes for all persons living at this address.

Mother / Father / Brother / Sister / No prior relationship
Wife / Fiancé / Girlfriend / Mother of Child
Friend/acquaintance / Grandmother / Grandfather / Other:
If you live in a private apartment or house, do you believe you would have a higher chance of staying out of prison if you went to a half-way house or supportive housing instead of your current address? / Yes No
Ethnicity: / African American / Hispanic / Latino / White (non-Hispanic) / Asian / Other:
Marital Status: / Never Married / Married / Engaged
Divorced / Widowed / Common-law married
How many children do you have?

Please list all your children, their ages, and their mothers’ names:

Child’s Name / Age / Mother’s First & Last Name / Child’s Name / Age / Mother’s First & Last Name
1 / 5
2 / 6
3 / 7
4 / 8
Are you currently required to pay child support for any of your children? / Yes No Not Applicable
What is your total current monthly child support payment? / $


CRIMINAL HISTORY

Please tell us the dates and crimes for which you have been convicted (or pled guilty or no contest to) in your lifetime, beginning with the most recent conviction. Include all arrests that led to conviction. Use the back of this page for additional space if necessary.

Conviction / Sentence
Start Date / Sentence Completion Date / Sentence Type / Charge(s)
Misdemeanor / Felony / month/year / month/year / Probation / County Jail (Rikers) / State Prison / Federal Prison / Juvenile System
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Check here if you have been arrested more times than you can remember (you must still complete as much of the above section as possible).
Check here if you have never served a prison sentence.

For what crime(s) were you convicted for your most recent sentence?

Years / Months
Time served on your most recent sentence:
Total prison time served in your entire lifetime:

Please describe the situation that led to your most recent incarceration:

Number of trips to prison:
Number of trips to jail (if separate from prison trips - include trips to Rikers but not central booking or precinct lockup):

Number of times you have been arrested (include all arrests regardless of indictment and/or conviction):

1 / 2 / 3 / 4 / 5 / 6 - 10 / 11 - 15 / 15+

List all of the aliases you have been arrested under:

Did you receive reduced time on your most recent sentence for providing information on another person's criminal activity? / Yes No N/A
Were you guilty of committing the most recent crime you were sentenced for? / Yes No N/A
Have you ever been sent back to jail/prison for violating parole? / Yes No N/A
If yes, what caused the violation? / New felony Technical violation

If this was not your first trip to prison, how long were you out between your prior and your most recent prison term?

Months / Years / N/A

If this was not your first prison term, what were the factors that caused your most recent return to prison?

Have you ever been …

  • arrested for a sexual offense?
/ Yes No
  • convicted of a sexual offense?
/ Yes No
  • received a sexual disciplinary case while incarcerated?
/ Yes No N/A
  • convicted of a violent offense?
/ Yes No

If you answered 'yes' to any of the above, please explain the situation.

If you are not accepted to Defy, how likely (percentage) is it that you will return to prison? / %
If you are accepted to Defy, how likely (percentage) is it that you will return to prison? / %
If you were given a urinalysis for drugs right now, would you pass it? / Yes No Unsure

Please explain your response above (whether you answered “yes,” “no,” or “unsure”).

RELEASE INFORMATION

The questions in this section refer to your most recent sentence. If you have not been incarcerated, please answer only the questions that apply to your situation.

Release Date: / Month: / Year: / N/A
Are you currently on probation or parole? / Yes No
If you are currently on probation or parole, what agency do you report to? / Federal Probation State Parole City Probation
Most recent or current probation/parole officer's name:
Probation/parole officer's phone number:
Parole office you report to:
Parole office address: / City: / State: / Zip:
Do your probation or parole conditions allow you to drink alcohol? / Yes No
How many times per month are you mandated to report to your PO?
How would you describe your relationship with your PO? / Excellent Good Average Difficult Very Difficult

Anything else we should know about your release or parole/probation situation?

Are you currently on an electronic monitor? / Yes No

What are your current probation/parole conditions? Include curfews and any mandated activities (anger management, drug classes, etc.). Include days and times of mandated activities and curfews.

Curfew / Completed
Current(days and times):
Drug treatment / Completed
Currently attending (days and times):
Alcoholics Anonymous / Completed
Currently attending (days and times):
Narcotics Anonymous / Completed
Currently attending (days and times):
Home visits / Completed
Current (days and times):
Other
(please describe) / Completed
Currently attending (days and times):
Other
(please describe) / Completed
Currently attending (days and times):
Other
(please describe) / Completed
Currently attending (days and times):

EDUCATION

Did you earn a high school diploma? / Yes No
If no, what was the last grade you completed in school?
Did you earn your GED? / Yes No
Did you take college classes inside prison? / Yes No

If you answered yes to the above question, please name and describe any college classes you completed inside prison.

Did you complete any vocational classes inside prison? / Yes No

If you answered yes to the above question, please name any vocational certificates received inside prison.

Have you completed any college classes outside of prison? / Yes No
Have you earned a college degree? / Yes No

If you answered yes to the above question, please name the degree(s) earned, the institution, and your major/minor areas of study.

EMPLOYMENT HISTORY

Are you currently employed? / Yes No
Who is your current employer?
Name of your direct supervisor: / Supervisor’s Phone Number:
Employer Address: / City: / State: / Zip:
When did you start your current job?(month/year)
What days and hours do you work at your current job? / Days: / Hours:
Have you ever had a sales job, either in legal or illegal endeavors? / Yes No

If you answered 'yes,' please describe the position.

Please list the last 5 jobs you have worked, beginning with the most recent and working backward. Please include any illegal work where you feel you learned useful skills. Please include employer name and job title where applicable.

Start Date / End Date / Name of Company / City, State / Job/Role
1
2
3
4
5

Have you ever started a business, either legitimate or illegal? If so, please list and describe.

Start Date / End Date / Description
1
2
3
4
5

FINANCE

Do you currently have an active bank account at a financial institution? / Yes No
Are you currently earning any income? / Yes No
Are you currently receiving public assistance or other services from HRA? / Yes No

If you answered 'yes,' please describe the services you are currently receiving.

Please list your top 5 sources of income, from largest to smallest.

Income Source / Amount received per payment / Frequency (weekly, monthly, etc.)
1
2
3
4
5

Please list your top 5 expenses, from largest to smallest.

Expense / Amount / Frequency (weekly, monthly, etc.)
1
2
3
4
5

PERSONAL DEVELOPMENT

While incarcerated, other than the college or vocational classes you listed earlier in the application, what additional productive or positive activities did you took part in? Include any jobs, classes, workshops, therapy, organizations, and other activities.

Start Date / End Date / Description
1
2
3
4
5
6
7
8

Since your release, what prisonre-entry programs have youparticipated in? Include the dates of your involvement, and any certificates you received.

Organization / Dates of Participation / Description / Received Certificate?
1 / Yes No
2 / Yes No
3 / Yes No
4 / Yes No
5 / Yes No

Please list and describe any other volunteer, community service, self-help, or other activities you have taken part in outside of prison.

Start Date / End Date / Organization / Description
1
2
3
4
5
6
7
8

Please describe any other activities you participate in for personal growth and the frequency of those activities. Include any activities you feel fit this description (e.g. physical fitness, religious/spiritual, family, hobbies, etc.).

Activity / Frequency
1
2
3
4
5

OTHER

What are your regular time commitments, outside of employment or probation/parole requirements?

Description / Day(s) / Time
1
2
3
4
5
6
7

Please describe why you would like to participate in Defy Ventures?

Please describe the personal attributes or experiences that would make you a good candidate for Defy Ventures?

1