Higher Ground Women's Recovery House
Program Application Form
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Date of application *
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Phone Number *
Applicant's Full Name *
DOB *
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/
DD
/
YYYY
Last 4 of Social Security Number *
DOC # (If Applicable)
Email Address *
Current Living Situation and Since When? *
Previous Living Situation and How Long? *
Expected move-in Date *
MM
/
DD
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YYYY
Highest Level of Education *
Marital Status *
Required
Race *
Do you have a Social Security Card? *
Required
Do you have your Birth Certificate? *
Required
Do you have a valid Driver's License? *
If Yes, please provide Driver's License ID# below
Required
Driver's License ID#
Do you have your own vehicle? *
Required
Do you understand that if you are not on legal disability or retirement that you will need to maintain full-time employment to participate in our housing? *
Required
Source of Income *
Wages *
Employer Name *
(If Applicable)
How long have you been employed? *
If you are not currently employed, write N/A
Name of Spouse/Significant Other *
Do you have children? *
Required
Do you have visitation with your children? *
If you do not have children, check no
Required
If yes to having visitation, what days or how often? *
Are you pregnant? *
Required
If pregnant, how far along?
How much is your monthly Child Support? (if applicable)
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