Unity House Application

As of 8/22/2014

APPLICATION

POC: Dennis Haut Cell (563) 210-1513 or Jamie McWade Cell (563) 275-6728 Fax (563) 359-8300

Or mail to: 2625 Crestview Drive, Bettendorf IA 52722

NAME:______BIRTH DATE: ______TODAY’S DATE:______

HOME PHONE #:______CELL PHONE #______

MALE or FEMALE ______ABLE TO SLEEP ON TOP BUNK? Yes No

______MARRIED ______SINGLE _____DIVORCED ______SEPARATED _____WIDOW

CURRENT ADDRESS:______HOW LONG?______

RENT:______UTILITIES: ______

EMPLOYER’S NAME:______INCOME______PHONE______

EMPLOYER’S ADDRESS:______LENGTH OF EMPLOYMENT?______

OTHER INCOME SOURCE(S)______AMOUNT______

COUNSELOR’S NAME:______

ADDICTIONS or DRUGS USED, (including alcohol):______

EVER CONVICTED OF ANY VIOLENT CRIMES:______

ARE YOU ON THE SEX REGISTRY:______

DO YOU HAVE ANY PENDING CHARGES OR LITIGATIONS:______

NEAREST LIVING RELATIVE (EMERGENCY NOTIFICATION)

NAME RELATION ADDRESS PHONE #

______

PERSONAL REFERENCES

NAME RELATIONSHIP ADDRESS PHONE#

______

Sobriety Date: ______Sponsor's Name ______How Long?______Do you smoke?______

Probation Officer’s Name: ______Phone No.:______

Doctor’s Name: ______Phone No.:______

Prescribed Medications:______

______Are you on the Methadone Program? ______Counselor: ______

Allergies:______

The above statements are true and accurate. By signing this application, I authorize reference

disclosure only for purposes of joining the Unity House of Davenport.

Applicant Signature:______Date:______

Form UH-1 Unity House Application