Good Samaritan House Hotel Voucher Pre-Screen Application Name * First Name Last Name SSN * Date of Birth * MM DD YYYY Age * Male or Female * Male Female Phone * (###) ### #### Most Recent Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Referred By * Phone number of Person Who Referred You * (###) ### #### Names, DOB, Genders of persons staying with you * Previous Shelter Stays * Dates of Previous Shelter Stays Do you have a place to stay tonight? * Yes No Are you currently a victim of domestic violence? * Yes No Reason for Seeking Emergency Shelter * Living in Emergency Shelter Sleeping in a car/street/park Lived in Transitional Housing Unit prior to living in a car/park/or on the street Being evicted within 14 days with court order Resided in institution for 90 days and will be discharged within 14 days Fleeing domestic violence. Seeking to file emergency protective order within 24 hours Legal Information Have you ever been convicted of any of the following? * Weapons Charge Unpaid Fines Failure to Appear None of the Above Do you have any of the following legal issues? * Pending Court Dates Pending Charges None of the Above Medical Information: List any medical conditions: * Prescribed Medications: * Do you have these meds? Yes No N/A Drug Use History * Can you pass a 30 day drug screen? * Yes No Can you refrain from drinking alcohol? * Yes No Application Affirmation To submit your application, you must affirm that all information you completed above is correct. By entering your digital signature below, you are affirming UNDER PENALTY OF PERJURY that all the information is correct. Typing your name in the box below will constitute your electronic signature: * Today's Date * MM DD YYYY By clicking on the "Confirm" button below, I am affixing my electronic signature, which is legally equivalent to my handwritten signature. Thank you!