Apply today!Click here to read Rules and Requirements Application Name * First Name Last Name Date of Birth MM DD YYYY Social Security Number: Current Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Known food/drug Allergies: * List all prescribed medications * Requested Date of Move-in: * MM DD YYYY Are you currently on Probation or Parole? * Yes No If yes, Name of Parole Officer or Probation Agent: Are you transitioning from a detention center, treatment facility, or homeless shelter: * Anticipated Release Date From: MM DD YYYY List of all charges: * Where you under the influence of drugs/ alcohol when crime was committed? * Yes No Please explain in detail any violent charges: * Do you require any special accommodation? If so, please explain: * How did you hear about us? Option 1 Option 2 Agreement Click checkbox below I attest that I have provided honest and accurate information to the best of my ability. I have read all materials provided to me and understand that by signing below, I agree to follow all Subimago Inc. house rules and policies. A copy of the House Rules has been provided to me as part of this application. Upon acceptance to program and taking residency, I agree to hold harmless Subimago, Inc., On the Mend, L3C, corporate officers, property owners, independent service contractors, and all service providers from all claims, actions, and liabilities. I authorize Subimago Inc. and On the Mend. L3C to share information per needed with all government or private parties and/or their representatives as it relates to the application process and housing status while living at Subimago Inc. sober living. I understand and agree that all payments for programs/ services are non-refundable. Reasonable accommodation will be provided upon request for those with disabilities. I have read both statements above, understand its contents, and voluntarily agree to its terms. Signature * Type name to digitally sign Date * MM DD YYYY Thank you!
