Date *

MM

DD

YYYY

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Do you have a valid Arkansas ID or Driver’s License? *

Yes

No

Do you have a Social Security Card? *

Yes

No

Do you have a Birth Certificate? *

Yes

No

Have you ever been convicted of a charge of a sexual nature?

Yes

No

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Are you a Veteran? *

Yes

No

Do you have any probation or parole obligations? *

Yes

No

Are you currently under probation or parole supervision and mandated by the justice system to take part in a transitional recovery program? *

Yes

No

Do you have any active or absconding warrants? *

Yes

No

Have you been clinically diagnosed with any mental illnesses? *

Yes

No

If so, are you currently taking prescription medication? *

Yes

No

Do you have any health/medical problems (small or major) (e.g., high blood pressure, etc.)? *

Yes

No

If so, do you take prescribed medications? *

Yes

No

Are you diabetic? *

Yes

No

If so, are you taking insulin syringes, pins, etc.? *

Yes

No

Have you had seizures in the past? *

Yes

No

Do you have any allergies (irritant or non-irritant)? *

Yes

No

Do you acknowledge the terms and conditions of the initial “black-out” and probationary phases? *

Yes

No

Are you capable of working a 40-hour-per-week job? *

Yes

No

Are you on disability? *

Yes

No