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Applicant Questionnaire
* Indicates required question
Email
*
Your email
Full Name
*
Your answer
Phone number
*
Your answer
Date
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MM
/
DD
/
YYYY
Age (Must be at least 21)
*
Your answer
Are you a sex offender?
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Yes
No
What is your addiction to?
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Your answer
What town and state are you from?
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Your answer
What county do you live in?
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Your answer
What work experience do you have?
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Your answer
List all medication & what it's used for**(Medications will have to be discussed with director BEFORE acceptance)
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Your answer
Are you under the care of a family doctor?
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Yes
No
Do you have 6 months worth of refills on your prescriptions?
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Yes
No
Do you have any form of Hepatitis or Aids?
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Yes
No
Do you have any health problems or medical conditions that could keep you from working an 8 hour work day?
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Yes
No
Do you have a history of seizures?
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Yes
No
Do you have any heart problems that require you to take nitroglycerin tablets?
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Yes
No
Are you or have you ever been treated for any mental issues or disabilities? (If so explain)
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Your answer
Do you have any toothaches, earaches or infections at this time that will need medical attention in the next six months to a year? (If so explain)
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Your answer
Do you have any problems with you vision at this time that will need a doctor's attention in the next six months to a year?
*
Yes
No
Are you allergic to Poison Ivy, Poison Sumac or Poison Oak?
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Yes
No
ATTN:
We are not a medical facility and in some cases we will not be able to accept men with severe medical conditions. If you lie about a medical condition and have to go to the Dr. while in this program, you will be dismissed.
Are you on probation or parole?
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Yes
No
Probation Officer and what county/state (YOU MUST HAVE A LETTER FROM YOUR P.O. STATING THEY HAVE ALLOWED YOU TO BE HERE!)
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Your answer
Do you have any upcoming court appearances?
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Yes
No
If so, tell us the dates County/Court and reasons.
*
Your answer
ATTN:
COURT ISSUES MUST BE RESOLVED BEFORE ENTRY. FAMILIES ARE RESPONSIBLE FOR ALL LEGALITIES WHILE RESIDENT IS IN PROGRAM. IF A COURT DATE CANNOT BE POSTPONED - IT MUST BE DISCUSSED AND APPROVED BY DIRECTOR. ABSOLUTELY NO COURT APPEARANCES WILL BE ALLOWED.
Do you have a valid driver's license?
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Yes
No
Marriage status
*
Married
Divorced
Single
Widowed
Do you have children? If so, what ages
*
Your answer
People not allowed to visit (Example: ex girlfriend, friend, ect.
Your answer
Do you have a girlfriend, wife or ex-wife the plan to visit you while you are enrolled in our program? If yes, Name
*
Your answer
Does she use drugs
*
Yes
No
Do you have any family issues going on? If so, explain
*
Your answer
ATTN:
Must have current Flu and Hep A vaccinations
Did you read the above ATTN: statement
*
Yes
No
ATTN:
Must contact John 3:16 Ministries Print Shop to set up an interview after completing questionnaire. 870-569-4956
Did you read the above ATTN: statement
*
Yes
No
**FOR OFFICE USE ONLY**
Must have applicant sign and date at interview
Signature:_______________________________________________________________________
Date:__________________________
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