ApplicationPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone # *Current Address Date of Birth *Marital Status *Gender *Race *Emergency Contact *Name | Phone # Emergency Contact Phone # *Name | Phone # Date Group Long Drug(s) of Choice *How Long Clean/Sober? *Years | MonthsSponsor's Name & Number *Name of Home Group *Mental Health Disorder? *YesNoSuicide Attempts *YesNoCurrent Legal Charges *YesNoWhat are they? *Current Medications *YesNoWhat are they? *Any history of violent offenses? *YesNoProbation or Parole *YesNoProbation or Parole Officer Name & Number *Place of Employment *Employment Phone #Referred ByName | Phone #Projected Arrival Date *Complete Screening Background Consent Form YesNoIn connection with my application for a rental/lease (the "Landlord") may request background records on me from Complete Screening Inc (CSI). I understand that these reports may include social security trace, credit bureau reports, criminal background searches, department of motor vehicle records, sex offender registries and other governmental public record sources. By signing below I give my consent and authorization to this landlord and any agency contacted in connection with this application to obtain the investigative reports as listed above. I release and hold harmless any individual, corporation, or private or public entity from any and all causes of action that might arise from furnishing to the landlord and/or Complete Screening Inc information that they may request pursuant to this release. A photo or faxed copy of this release will act as the original and shall be valid for this and any future reports or updates that may be requested by the Landlord in connection with my application. SignatureDate Submit