1. NAME: Last First Middle SSN: What name do you prefer to be called:? Date of Birth Place of Birth City & State. Age: Ht: Wt: Eye Color: Hair Color:

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1 STEPPING STONES MINISTRY Elmwood Avenue Church of God 1427 Elmwood Avenue Columbia, SC Telephone , Ext. 207 FAX: Application for Residence Date: 1. NAME: Last First Middle SSN: What name do you prefer to be called:? Date of Birth Place of Birth City & State Age: Ht: Wt: Eye Color: Hair Color: Any Identifying Marks/Tattoos: Address you claim as your residence: 2. Emergency Contact Information: (Give Two Point of Contacts) City: State: Telephone Number: City: State: Telephone Number: 3. Military Services: Branch: Dates : Page 1 of 5, 1/3/2012, \\ADMINOFFICEPC\SharedDocs\SSM - Stepping Stones Ministry\Transitional Housing - SSM\SSM Trans.

2 Type of Discharge:. Rank: 4 EDUCATION: High School GED College Special Vocational Training: Last date of school attended: Course of Study: Hobbies/Interests You have developed: 5. WORK HISTORY: List the last five jobs you held. Start with the current or last. You may use a blank sheet of paper to complete the information Employer Name: Address of employer: Telephone Number: Name of Supervisor: Dates of Employment. From: To: Position or Job Held: Reason for Leaving: Are you eligible for rehire: Yes No don t Know 6. Do you have any known physical or mental conditions? Yes No If yes, describe the Condition: Does the condition require medical treatment? Yes No State the Conditions (Diagnosis) What Treatment is required? Are you taking any medically prescribed medications for the condition? Yes No Have you received treatment for Alcohol or other substance addiction before this stay? Yes No If Yes. How many times prior to this time Page 2 of 5, 1/3/2012, \\ADMINOFFICEPC\SharedDocs\SSM - Stepping Stones Ministry\Transitional Housing - SSM\SSM Trans.

3 Where Dates of treatment What age did you begin to use alcohol or the drug of your choice? Do you have a history of seizures? Yes No If so, Diagnosis and description of seizures: Rate or frequency of seizure: Date of last seizure: Are you in need of any immediate medical or dental treatment? Yes No If Yes, Explain: Have you ever received Psychiatric Care Yes No? If yes, please explain 7. Are you a member of a church? Yes No. Which Church: Do you attend church regularly? yes No 8. How will you pay for your stay at Stepping Stones Recovery House? Describe your current financial obligations: What are you doing to meet your financial responsibilities:? Do you have an income? Yes No. What is the source of income How Much do you receive:? Do you currently receive Food Stamps? Page 3 of 5, 1/3/2012, \\ADMINOFFICEPC\SharedDocs\SSM - Stepping Stones Ministry\Transitional Housing - SSM\SSM Trans.

4 9. Do you have a current ID card or driver s license? Yes No. If yes, what State: Year Issued: Valid Date Drivers License Number Do you have a Social Security Card? 10. Do you have transportation? Yes No If Yes describe: 11. What kind of work will you be seeking while at the Transitional House? 12. Do you have a current job or the probability for work? Yes No OTHER COMMENTS: LEGAL INFORMATION: Have you ever been charged with Criminal Domestic Violence? Yes No If yes explain: Have you ever been charged with any Sexual Offense? Yes No If Yes Explain: Are you required to register as a Sex Offender? Yes No Have you been charged/convicted for criminal offense including motor vehicle violations? Page 4 of 5, 1/3/2012, \\ADMINOFFICEPC\SharedDocs\SSM - Stepping Stones Ministry\Transitional Housing - SSM\SSM Trans.

5 Are you presently on Parole or Probation? Yes No if yes, list your Parole/Probation Officer s name, phone number and address: Name: Phone Number: Have you ever been on Parole or Probation? Yes No. If yes list your Parole/Probation Officer s name, phone number and address: Name: Phone Number: Give your attorney s name, phone number and address: Name: Phone Number City: State: Telephone Number: Please Print your Name: Signature: Date: Final approval for Admission to the Stepping Stones Ministry Transitional Housing will come from the Stepping Stones Ministry Board and Director of Housing Program. Page 5 of 5, 1/3/2012, \\ADMINOFFICEPC\SharedDocs\SSM - Stepping Stones Ministry\Transitional Housing - SSM\SSM Trans.