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Basic Information Sheet / Probation

  1. If applicable

  2. Write N/A if not working

  3. Have you lived at this address 3 or more consecutive years? *

  4. If applicable

  5. If applicable

  6. Citizen of the United States?*

  7. Legally in the United States on a temporary basis?*

  8. Select one. Are you:*

  9. List all children (including stepchildren)

  10. If applicable

  11. If applicable

  12. If applicable

  13. If applicable

  14. Do you need to list more children?*

  15. Education Level*

  16. Are you currently employed?*

  17. Were you ever fired from a job?*

  18. Additional source of income?*

  19. Have you ever been in the Armed Services?*

  20. Which branch?*

  21. From what date to what date?

  22. Type of discharge*

  23. Are you currently covered by insurance?*

  24. Are you the policy holder?*

  25. What is relationship to you?

  26. Have you been seriously ill or injured during the past five years (include current illness)*

  27. Currently prescribed medications?*

  28. Are you taking the medications prescribed to you?*

  29. Ever involved with Juvenile Court?*

  30. Any prior adult convictions?*

  31. Any pending charges against you?*

  32. Have you ever been on probation?*

  33. Currently on probation or parole?*

  34. Do you or have you used alcohol?*

  35. Which best describes your pattern of alcohol use:*

  36. Do you or have you used drugs?

  37. Which best describes your pattern of drug use:*

  38. Have you partaken in any counseling within the past 5 years? (Include any present counseling)*

  39. History of alcoholism or drug addiction in family?*

  40. Select all that apply*

  41. Do you feel you have an alcohol or drug use problem?*

  42. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. I have reviewed this document and the statements it contains are true to the best of my knowledge, information, and belief.

  43. Leave This Blank:

  44. This field is not part of the form submission.