Application for Admittance
The Bridge Restoration Program Application for Admittance. All sections must be completed. AFTER you have filled out the online application the next step is to call 831-372-2033 and scheduling an interview. We look forward to hearing from you.
* Required
Email address
*
Your email
Name (First, Last, Middle Initial)
*
Your answer
Address, City, State, Zip
*
Your answer
Phone Number
*
Your answer
Are you registered in any jurisdiction as a sex offender?
*
No
Yes
If you answered yes, give details, including where you have registered.
*
Your answer
Do you have any medical conditions for which you are seeing a physician, or are taking prescriptive medication?
*
No
Yes
If yes, give details, including the specific medications you are taking:
*
Your answer
Do you have any medical conditions that would preclude you from working in an environment that required repetitive lifting of at least 50 lbs?
*
No
Yes
If yes, what condition?
*
Your answer
(For Women) When was your LMP Date?
MM
/
DD
/
YYYY
Birthdate
*
MM
/
DD
/
YYYY
Age
*
Your answer
Gender
*
Male
Female
Hair Color
*
Your answer
Eye Color
*
Your answer
Height
*
Your answer
Weight
*
Your answer
Marital Status
*
Single
Married
Separated
Divorced
Widowed
Other:
Number of Children
*
Your answer
Ages of Children
*
Your answer
Social Security #
*
Your answer
Driver's License #
*
Your answer
State Issued (Driver's License)
*
Your answer
Expiration Date (Driver's License)
*
Your answer
If No Driver's License
*
Suspended
Revoked
Expired
Never Applied
Other:
Do you have any DUIs in the past 12 years?
*
Yes
No
Other:
Have you previously been in our program?
*
Yes
No
If yes, when?
Your answer
Have you been in any other programs? (List them below)
*
Your answer
Have you ever been convicted of a felony?
*
Yes
No
If Yes, give details (i.e. when, where, for what)
Your answer
Have you ever been in custody with the CDCR or in another state?
*
Yes
No
If Yes, give details (i.e. when, where, for what)
Your answer
Are you (or will you be) on parole or probation?
*
Yes
No
If Yes, for how long, who is your parole/probation officer (including telephone #)
Your answer
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