Xchange Recovery Supportive Housing Application

Xchange Recovery Supportive Housing Application

Please complete this application honestly and thoroughly – incomplete applications will not be considered. Program fee required upon entry.
Date

Month Day Year
Full Name *

First Name Middle Init/Name Last Name Suffix (optional)
Nickname
*

Male Female
Social Security Number
Date of Birth *
Cellular Number

Area Code Phone Number
Home Number

Area Code Phone Number
How long have you lived in Vancouver
E-mail
example@example.com

Goals and Objectives
Briefly describe your goals for yourself and your family: *
How do you think Xchange Recovery can help you achieve these goals? *
Please review your application to make sure it has been completed thoroughly and to the best of your ability. We understand you may not recall a phone number, address or specific date, however, applications missing critical information will not be considered.
*

Applicant gives consent and authorizes Xchange Recovery to make any and all inquiries necessary to verify the information provided herein. This information includes, but is not limited to, the use of my social security number and direct contact with references and other individuals identified in the application.
Signature

Clear
Section below for staff only:
Date of Interview

Month Day Year
Date
Accepted into housing program

YES NO
Date of Entry

Month Day Year
Date
If no referred to:
Comments
Should be Empty:

Current Situation