Based In Northern California
EMPLOYMENT/SOURCE OF INCOME
Will someone other than yourself be responsible for your rent? Yes, No, if yes, please enter following information:
Note: Guarantor is required to fill out financial paperwork.
Are you currently taking Antabuse or any anti-craving medication.? Yes No If yes, list under medications below.
List of Prescribed or OTC medications you are taking
Do you have more than the above listed medications? Yes No If Yes, please list here:
Previous Treatment Facilities (including Sober Living homes , 5150 & 5250)
Have you Attended AA/NA, if yes, enter the following information
Have you ever been arrested or are you currently involved in any legal action (arrested, DUI's ) Yes or No if yes, explain. Use a separate piece a paper if you need more room.
If you need letters confirming you are living in an SLE, please give all pertinent information to the Facility Program Manager.
Personal References. 1 of the 3 may be a family member
Disclaimer of Rights:
By sending this email, I certify my answers are true and correct and I hereby authorize Fountain Recovery and its agents to verify the information. I understand if I am approved to live in the SLE and it is later learned that I falsified any information I will be terminated immediately and all monies paid will be forfeited. I understand that the SLE is monitored by live cameras. I understand that drug and alcohol screens are monitored and that I may be asked to test at any time.