Applicant Questionnaire
Email address *
Name *
Phone number *
Date *
MM
/
DD
/
YYYY
Age (Must be at least 21) *
Are you a sex offender? *
What is your addiction to? *
What town and state are you from? *
What county do you live in? *
What work experience do you have? *
List all medication & what it's used for**(Medications will have to be discussed with director BEFORE acceptance) *
Are you under the care of a family doctor? *
Do you have 6 months worth of refills on your prescriptions? *
Do you have any form of Hepatitis or Aids? *
Do you have any health problems or medical conditions that could keep you from working an 8 hour work day? *
Do you have a history of seizures? *
Do you have any heart problems that require you to take nitroglycerin tablets? *
Are you or have you ever been treated for any mental issues or disabilities? (If so explain) *
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) *
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? *
Are you allergic to Poison Ivy, Poison Sumac or Poison Oak? *
Are you on probation or parole? *
Probation Officer and what county/state (YOU MUST HAVE A LETTER FROM YOUR P.O. STATING THEY HAVE ALLOWED YOU TO BE HERE!) *
Do you have any upcoming court appearances? *
If so, tell us the dates County/Court and reasons. *
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? *
Marriage status *
Do you have children? If so, what ages *
People not allowed to visit (Example: ex girlfriend, friend, ect.
Do you have a girlfriend, wife or ex-wife the plan to visit you while you are enrolled in our program? If yes, Name *
Does she use drugs *
Do you think she should be allowed to visit? *
Do you have any family issues going on? If so, explain *
ATTN:
Must have current Flu and Hep A vaccinations
ATTN:
Must contact John 3:16 Ministries Print Shop to set up an interview after completing questionnaire. 870-569-4956
**FOR OFFICE USE ONLY**
Must have applicant sign and date at interview


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