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- 1. Victoria House ApplicationPart1 of 2. Prospective Resident Details, Application/Resident Status Update.Robert E. Widing IIIPart 1 of 2Drafted on 10/01/2008Revised on 05/17/2009Revised on 06/26/2009Revised on 11/19/2009Revised on 07/01/2010Revised on 10/07/2010This document provides no guarantees, commitments or responsibilities, remains the property of, and is subject to approval by; shareholding Member/s, Company Officer/s and/or the Authorized Responsible Agent and Legally Authorized Corporate Authority Appointed by Victorian House Collaborative LLC® to act on behalf of the Company. Authorization/s and/or Appointments to act on behalf of the Company and/or its Subsidiary; Victoria House in the Commonwealth of Pennsylvania are subject to the LLC' Operational Agreements and the laws of its Jurisdiction. Agreement/s, Contract/s and/or Leases are; subject to Approval, Non-Binding, Sever-able and may change until consideration is exchanged. Victorian House Collaborative LLC® is the Successor to the Arizona based Limited Liability Corporation Victorian Properties LLC® which is a Separate, Pennsylvania Based Limited Liability Corporation, yet the Terms, Names, Conditions, Agreements, Forms and/or any Legal Arrangements with the Former Governing Entity Remain Valid. Victoria House Collaborative LLC® reserves all rights afforded under Federal, State, Commonwealth, Local and Provincial Authorities including but not limited to the right/s of; Limited Liability, Civil and/or Criminal Restitution, Lien and Rights given under applicable Landlord Tenant Acts or Laws in/lieu of a Governing Act via; Statute, Tort, Judgment or other Legal Remedies. Agreements with Victorian House Collaborative LLC® are subject to the Laws of its State of Incorporation and/or Operation. Agreements under the LLC' stamp/seal supersede that of any regional law/s with the exception of Applicable Federal Statutes that may be proven via; Hearing, Trial or Judgment set by Governing Courts of; District (Magisterial), County Court of Common Pleas, District Court of Appeals (Circuit), State and/or the Supreme Court of the United States of America in Constitutional and/or Amendments therein, to Uphold the Law of the Land.<br />DBA VICTORIA HOUSE<br />PART -1. A) Current Living Arrangements & Related<br />Full Name: ____________________________________________________________________<br />Current Residents: Fill in as if applying for first time for updating.<br />Are you coming from a Rehabilitation or Treatment center?YES_____NO_____<br />Are you coming from a Halfway/Group House or Similar?YES_____NO_____<br />If you answered YES to either question, please write down the name of center, institute or house including the type of service they provide, i.e.; drug/alcohol rehabilitation, counseling (types) etc.<br />* If NO, skip to 1.b) Address and write your current mailing address or primary residency.<br />Facility (Examples; Salvation Army Rehabilitation Center, Snow House or Maria House Projects):<br />Facility: _____________________________________ Length of Stay: ____________________<br />Purpose of Stay: ________________________________________________________________<br />Discharge Date: ______/______/______ OR Lease/Contract End Date: ______/_______/______<br />References: Counselor, Psychiatrist, Employer, House Manager, Center Coordinator, Therapist etc.<br />New Applicants: Please provide at least 1 written reference to: Victoria House LLC, Cc: Rob W.<br />Reference Name: _________________________________ Relation: _______________________<br />Work# __________________ Mobile# ___________________ Position: ____________________<br />1. B) Current Address and Contact Information<br />Location:______________________________________Apt/Room-#: ___________________ <br />City: _____________________State: _________________Zip: _________________<br />Phone:H: ____________________ M: _____________________W:___________________<br />Email/s 1st: __________________________ 2nd: _____________________________<br />N/O/K:Name: __________________________________ Relation: ____________________<br />Phone:H: __________________ W: ____________________ M: _____________________<br />NOTE: Next of Kin MUST BE CONTACTABLE. Write 2 CURRENT Phone Numbers. <br />PART -2. A) Criminal History Information (Current Residents: Re-Enter Details)<br />Please answer HONESTLY. Falsifying information may have serious legal consequences.<br />1. Do you have a criminal history?YES______NO______<br />2. If YES, is it a Felony?YES______ NO______<br />3. Are you on Probation or Parole?YES______ Fill (a1)NO_____ Fill (a1)<br />(a1) If YES to last question, please provide; type of paper/s, P/O or Agents; name, contact number (w/extension), duration and ALL conditions if any.<br />Current Residents: Treat as new application noting everything Before AND During stay:<br />_______________________________________________________________________________<br />_______________________________________________________________________________<br />_______________________________________________________________________________<br />_______________________________________________________________________________<br />_______________________________________________________________________________<br />(a2) If YES to either questions, please BRIEFLY, describe the charge/s. Do not put down any unresolved or non-disclosed information that may put you at risk of further prosecution. Please write down only what you have been convicted of, have satisfied judicial punishment for and are absolved of or still involved in the reparations process; State Parole, County Probation etc.<br />*If this section is not applicable, please write a large N/A.<br />______________________________________________________________________________<br />______________________________________________________________________________<br />______________________________________________________________________________<br />______________________________________________________________________________<br />______________________________________________________________________________<br />2. B) Outstanding Legal or Related Issues<br />If you have any outstanding legal issues such as court appearances, mandatory drug or alcohol tests, probation officer visits, mandatory counseling etc. Please write them down. This is not to be intrusive but Victoria House Management must know if there are to be unexpected visits or issues from legal or Law Enforcement Authorities.<br />*If this section is not applicable, please write a large N/A.<br />______________________________________________________________________________<br />______________________________________________________________________________<br />______________________________________________________________________________<br />______________________________________________________________________________<br />______________________________________________________________________________<br />PART -3. A) Employment and Financial Viability.<br />This section is to establish how you are planning to support yourself. Please only fill out what is applicable to you. You will not be judged, marked or attain any advantage in this section as its only aim is to establish if you will be able to afford to live at Victoria House. For example, if you do not plan on working due to disability, or are unemployed and family are going to help pay rent until employment or studies are started, list it.<br />Employment or Employable<br />Are you working or have a confirmed future job?YES________ NO_______<br />If YES, Please list your job and or upcoming job, including the name of the business, location details and the contact number of the business and/or a supervisor/manager.<br />______________________________________________________________________________<br />______________________________________________________________________________<br />______________________________________________________________________________<br />______________________________________________________________________________<br />______________________________________________________________________________<br />If NO, are you going to be looking for work?YES________ NO________<br />If YES or NO, briefly explain how you are going to be able manage financial obligations on an ongoing and sustainable basis. Also, If NO, write how you are going to better self/community?<br />______________________________________________________________________________<br />______________________________________________________________________________<br />______________________________________________________________________________<br />______________________________________________________________________________<br />______________________________________________________________________________<br />3. B) Government sponsored Disability Payments<br />Are you currently on a government subsidy or disability?YES_________ NO_________<br />If YES, will you be on this payment for 3 months or more?YES_________ NO_________<br />What is the name of this benefit?: ____________________________________________________<br />CASH ($) and/or FOOD STAMP (FS$) Entitlements: C$_______._______ FS$_____.______<br />If NO, will you be able to find alternate income source/s?YES_________ NO_________<br />DO YOU BELIEVE THAT YOU WILL BE ABLE TO MEET THE FINANCIAL OBLIGATIONS NEEDED TO LIVE AT VICTORIA HOUSE?<br />YES________NO________<br />PART -4. A) Alcohol and Drug Information<br />Victoria House is a recovery house for those recovering from drug/alcohol affliction. This section assumes a lot and therefore it is up to the individual as to how in depth he answers.<br />Are you primarily an:<br />________ Alcoholic<br />________Drug Addict<br />________Duel Diagnosed<br />________All of the above<br />What is your Drug of Choice (If primarily Alcoholic, put Alcohol)? _______________________<br />Current Residents: Treat as a new application. Note any Relapse/Incident/Hospitalization etc.<br />What other drug or drugs (if any) have you had a problem/s with (including prescription meds)?<br />______________________________________________________________________________<br />______________________________________________________________________________<br />______________________________________________________________________________<br />Have you Completed a 28+ day In OR Outpatient Program?YES_____ NO______<br />Do you have a Continuation of care or follow a Treatment Plan? YES _____ NO _____<br />4. B) Other Related Information<br />Current Residents: Include ANY Changes:<br />How long have you been clean from your primary DOC? _______________________________<br />How long have you been completely clean of all drugs/alcohol including prescription medication that is/was; not prescribed, not taken as prescribed, abused and/or not under medical supervision with regular consultations from a Doctor or Psychiatrist for psychotropic/scheduled medications?<br />AND<br />How long you have been clean of your Drug of Choice as well as any other drugs that you should not have taken? How long have you been a \" responsible\" clean person in recovery? And briefly detail your last relapse/hospitalization/arrest; informing; what drug/s, type/s of alcohol, why etc.<br />________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ All information is true and correct under, writ; for Sections 1 to 4: X_________________________<br />Applicant Signature SEAL<br />PART -5. A) Voluntary Medical Disclosure<br />This section like all others is kept with complete confidentiality. The purpose of this section is to help safeguard you as an individual from theft, false accusations and any other mishaps regarding prescription medication. Furthermore this will help to provide understanding of any conditions you may have. NOTHING in this section will influence your decision on admittance. Victoria House allows admittance based on the character of the individual NOT medical conditions.<br />This question is COMPLETELY optional<br />Do you have any medical conditions that you wish to notify Management about should you so provisions may be made to save you embarrassment, harassment or unnecessary bad feelings? This applies for any condition and Management can provide; extra privacy, extra sheets, lifts for preventative treatments of chronic life threatening conditions (may require documentation), additional disinfectants/detergents, better security, more separated food storage options etc.<br />YES_______NO_______<br />5. B) Mandatory Medical Information<br />Are you on any prescription medications?YES_______NO________<br />If yes, Please list the medications you are taking. Please note: You are responsible for your own medications. Management will not hold, dispense or place in security any of your medications. The security and management of your medications are your own responsibility; however, you MUST detail what you are on, keep your medications in labeled prescription containers, take as prescribed and notify Management of any changes including the collection of medication from a new or different doctor than that of your other medications.<br />Usage of non-prescribed, stolen and/or possession of non-prescribed medications may result in your Contract/Agreement Termination as per Clause *1-.Articles of Termination. Police involvement may be necessary. Always ensure you have valid prescriptions and Management knows of changes: Current Residents: List Meds W/Dosage. Write Down ANY Changes in the Last 3 Months:<br />_______________________________________________________________________________<br />_______________________________________________________________________________<br />_______________________________________________________________________________<br />_______________________________________________________________________________<br />_______________________________________________________________________________<br />Are any of these medications Scheduled (schedule 1, 2, 3, 4 or 5) or listed under the Federal Controlled Substance Act (Corporate Agent/Manager will Terminate residency if not informed)?<br />YES_______NO_______<br />If yes, list the medication/s in the above section. A YES answer is OK if DR. PRESCRIBED and Monitored. If so it’s recommended you purchase a lock box for security (can easily be arranged).<br />PART -6) Individual Considerations, Conditions, Issues or Agreements<br />Q1) Applicant/Resident has the following issues he believes need addressing. RESIDENT <br />________________________________________________________________________________<br />________________________________________________________________________________<br />________________________________________________________________________________<br />________________________________________________________________________________<br />Q2) Management/Corporate has the following issues to address: MANAGEMENT<br />________________________________________________________________________________<br />________________________________________________________________________________<br />________________________________________________________________________________<br />________________________________________________________________________________<br />Q3) Both Parties have respectfully come the following conclusion/s: RESIDENT & MANAGER<br />________________________________________________________________________________<br />________________________________________________________________________________<br />________________________________________________________________________________<br />________________________________________________________________________________<br />STATUTORY DECLARATION:<br />I, ____________________________ HEREBY SWEAR UNDER WRIT; ALL INFORMATION IN THIS AND ALL OTHER FORMS ARE TRUE AND CORRENT TO THE BEST OF MY ABILITY KNOWING THIS IS A SWORN DECLARATION UNDER LAW.<br />APPLICANT: (X)___________________________________/______/______/_____<br />SIGNATUREDATE<br />WHITNESS: __________________________________._____/______/______<br />PRINT NAMEDATE<br />ADDRESS:__________________________________/ (X):________________________<br />STREET, CITY, ZIPSIGNATURE SEAL<br />END PART 1 Of APPLICATION OR EXTENSION AGREEMENT<br />STAMP OR SEAL AUTH. MANAGER & RESPONSIBLE AGENT (PA) ROBERT WIDING, BA<br />INTERNAL USE<br />COMP: _______/______/______ APP/DEC__________________ DT______/_______/______<br />ASST: ______/_______/______ P2RA _____/______/_____ P2-SP Y____ N ____ C_____<br />