Res leasep1updated

VICTORIAN PROPERTIES LLC®2009. All Rights Reserved. 1
VICTORIAN PROPERTIES LLC®2009. AZ, USA.

Victoria House
Application
Part 1 of 2. Prospective Resident
Details, Application/Resident Status
Update.

Robert E. Widing III
Part 1 of 2

Drafted on 10/01/08
Revised on 05/17/09
Revised on 06/26/09
Revised on 11/19/09

This 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/Representative of Victorian Properties 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 are; subject to Approval, non-binding, sever-
able and may change until consideration is exchanged. Victorian Properties
LLC® is an Arizona based Limited Liability Company and reserves all rights
afforded under Federal, State, Commonwealth 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

APPLICATION INFORMATION PART 1 of 2 RESIDENT UPDATES/s
DBA TH
VICTORIA HOUSE. 1156 W. 11 STREET. ERIE, PA, 16502. (814) 528-5600 or (623) 313-4391


Remedies. Agreements with Victorian Properties 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
Judgement set by Governing Courts of; District (Magisterial), County, District
(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.

DBA TH

DBA
VICTORIA HOUSE. 1156 W. 11TH STREET. ERIE, PA, 16502. (814) 528-5600 or (623) 313-4391


DBA
VICTORIA

HOUSE
1.a) Current Living Arrangements & Related

Full Name: ____________________________________________________________________
Current Residents: Tick NO for the next 2 Questions.
Are you coming from a Rehabilitation or Treatment center? YES_____ NO_____

Are you coming from a Halfway/Group House or Similar? YES_____ NO_____
If you answered YES to either question, please write down the name of center, institute or house
including the type of service they provide, ie; drug/alcohol rehabilitation, counseling (types) etc.
* If NO, skip to 1.b) Address and write your current mailing address or primary residency.
Current AND Prospective Residents: If you have a TCM Please use as your Reference.
Facility (Examples; Salvation Army Rehabilitation Center, Snow House or Maria House Projects):

Facility: _____________________________________ Length of Stay: ____________________

Purpose of Stay: ________________________________________________________________

Discharge Date: ______/______/______ OR Lease/Contract End Date: ______/_______/______
Reference (Counselor, Psychiatrist, Employer, House Manager, Center Coordinator, Therapist etc.)

Reference Name: _________________________________ Position: ______________________

Work# __________________ Mobile# ___________________ Other# ____________________

1.b) Current Address and Contact Information

Address: ____________________________________________________________________
____________________________________________________________________

Phone: H: ____________________ M: _____________________W: ___________________

Other: _______________ E-mail: __________________________________________

N/O/K: Name: ___________________________________ Relation: ____________________

Phone: Home: _________________________ Mobile: _______________________________

DBA TH


NOTE: Next of Kin MUST BE CONTACTABLE. Write 2 CURRENT phone numbers

2.a) Criminal History Information (Current Residents: List any Changes if any)

Please answer HONESTLY. Falsifying information may have serious legal consequences.

1. Do you have a criminal history? YES______ NO______

2. If YES, is it a Felony? YES______ NO______

3. Are you on Probation or Parole? YES______ Fill (a1) NO_____ Skip (a1)

(a1) If YES to last question, please provide: Type of paper are you on? P/O or Agents
Name, Contact Number w/ext? Duration? ANY and ALL Conditions of Parole?
Current Residents: Treat as new application noting everything Before AND During stay:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

(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.
*If this section is not applicable, please write a large N/A.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2.b) Outstanding Legal or Related Issues

(b1)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.
*If this section is not applicable, please write a large N/A.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
DBA TH


3) Employment and Financial Viability.

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.

Employment or Employable
Are you working or have a confirmed future job? YES_________ NO_________

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.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

If NO, are you going to be looking for work? YES_________ NO_________

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?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Government sponsored Disability Payments
Are you currently on a government subsidy or disability? YES_________ NO_________

If YES, will you be on this payment for 3 months or more? YES_________ NO_________

What is the name of this benefit/s? _________________________________________________

CASH ($) and/or FOOD STAMP (FS$) Entitlements: $______._______pm FS$____________

If NO, will you be able to find alternate income sources? YES_________ NO_________

DO YOU BELIEVE THAT YOU WILL BE ABLE TO MEET THE FINANCIAL
OBLIGATIONS NEEDED TO LIVE AT VICTORIA HOUSE?

DBA TH


YES________ NO________

4.a) Alcohol and Drug Information

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.

Are you primarily an:

________ Alcoholic

________Drug Addict

________Duel Diagnosed

________All of the above

What is your Drug of Choice (If primarily Alcoholic, put Alcohol)? _______________________

Current Residents: Treat as a new application. Note any Relapse/Incident/Hospitalization etc.
What other drug or drugs (if any) have you had a problem/s with (including prescription meds)?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Have you completed or been in a 28+ day inpatient OR outpatient program? YES____ NO_____

Do you have OR require a continuation of care or follow a treatment plan? YES ____ NO ____

4.b) Other Related Information
Current Residents: Include ANY Changes:
How long have you been clean from your primary DOC? _______________________________

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?
AND
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.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

DBA TH


5.a) Voluntary Medical Disclosure

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.

This question is COMPLETELY optional
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.

YES_______ NO_______

5.b) Mandatory Medical Information

Are you on any prescription medications? YES_______ NO________

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.
Please understand, this is for your protection, in the case of stolen/missing meds, the usage of non
prescribed medications or the possession of non prescribed medications may result in your contract
termination. In some cases police involvement may be necessary. When multiple parties are
involved, whoever is most upfront and honest typically gets the benefit of doubt. Medication/s:
Current Residents: List Meds W/Dosage. Write Down ANY Changes in the Last 3 Months:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Are any of these medications Scheduled (schedule 1, 2, 3, 4 or 5) or listed under the Federal
Controlled Substance Act (Body corporate will terminate residency if not informed)?

Yes_______ NO_______

DBA TH


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).

6) Individual Considerations, Conditions, issues or Agreements

PLEASE COMPLETE Q1 and Q2 WITHOUT HOUSE MANAGER PRESENT

Q1) Applicant and/or Resident have and agreed/disagreed to address the following (Any Issues):

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Q2) I have the following Concerns and/or feel these Suggestions or Changes are worth mentioning:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Q3) This brought us both to the following conclusion/s: COMPLETE WITH MANAGER:
________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

COMPLETED:
APPLICANT (X) __________________________________ DATE ______/______/______

MANAGER (X) __________________________________ DATE _____/______/_______

END PART 1
STAMP OR SEAL AUTHORIZED REPRESENTATIVE (PA) ROBERT E. WIDING III
INTERNAL USE

COMP: _______/______/______ APP/DEC__________________ DT______/_______/_______
DBA TH


ASST: ______/_______/______ P2RA _____/______/_____ P2-SP Y____ N ____ C_____

DBA TH

Res leasep1updated

More Related Content

What's hot

Viewers also liked

Similar to Res leasep1updated

More from Rob WFlag

Res leasep1updated