NAME: (Print full legal name)
First Name:
Middle Name:
Last Name:
Suffix: N/A Jr Sr II III Other

Date of Birth:

DRIVER’S LICENSE NUMBER AND STATE: State: Number:

OTHER NAMES YOU HAVE USED IN THE LAST 10 YEARS:

(1)   

(2)

CURRENT LEGAL ADDRESS:       

Street/Apt#:

City:      County:     State:     Zip Code:                                                                         

NUMBER OF YEARS AT CURRENT ADDRESS: Months:  

PREVIOUS ADDRESSES FOR THE PAST 7 YEARS: Include dates at residence, city, state, and county.

DATES:         Street:

City    County   State

DATES:         Street:

City    County   State

DATES:         Street:

City    County   State

PLEASE CHECK YOUR RESPONSE

Select Yes No           1.             Have you used illegal drugs even once in the last 10 years?
If you answered yes to 1 please explain:

Select Yes No           2.             Have you used prescription drugs which were not prescribed to you in the last 10 years?
If you answered yes to 2 please explain:

Select Yes No           3.             Have you supplied drugs, alcohol, or tobacco products to a minor, or assisted a minor in obtaining drugs, alcohol, or cigarettes in the last 10 years?
If you answered yes to 3 please explain:

Select Yes No           4.             Have you ever been charged with an offense of driving while under the influence of drugs or alcohol? (ALL CHARGES ABOVE A CLASS C MISDEMEANOR)

If you answered yes to 4 please provide: DETAILS INCLUDE DATE, COUNTY, AND STATE WHERE EVENT OCCURRED. THE OUTCOME OF THOSE CHARGES. IF THERE IS MORE THAN ONE CHARGE, LIST THEM STARTING WITH THE MOST CURRENT CHARGE:

Select Yes No           5.             Have you ever pled guilty or no contest to a charge of theft, assault, burglary, forgery or falsification of documents, manslaughter, or murder. (ALL CHARGES ABOVE A CLASS C MISDEMEANOR)

If you answered yes to 5 please provide: DETAILS INCLUDE DATE, COUNTY, AND STATE WHERE EVENT OCCURRED. THE OUTCOME OF THOSE CHARGES. IF THERE IS MORE THAN ONE CHARGE, LIST THEM STARTING WITH THE MOST CURRENT CHARGE:

Select Yes No           6.             Are you currently under a probationary sentence or deferred adjudication for any offense? (ALL CHARGES ABOVE A CLASS C MISDEMEANOR)

If you answered yes to 6 please provide: DETAILS INCLUDE DATE, COUNTY, AND STATE WHERE EVENT OCCURRED. THE OUTCOME OF THOSE CHARGES. IF THERE IS MORE THAN ONE CHARGE, LIST THEM STARTING WITH THE MOST CURRENT CHARGE:

Select Yes No           7.             Have you ever knowingly been in possession of stolen property or property which was obtained through fraud or forgery?
If you answered yes to 7 please explain:

Select Yes No           8.             Have you ever been convicted, plead guilty, plead no contest, or given deferred adjudication for ANY misdemeanor or felony? (ALL CHARGES ABOVE A CLASS C MISDEMEANOR)

If you answered yes to 8 please provide: DETAILS INCLUDE DATE, COUNTY, AND STATE WHERE EVENT OCCURRED. THE OUTCOME OF THOSE CHARGES. IF THERE IS MORE THAN ONE CHARGE, LIST THEM STARTING WITH THE MOST CURRENT CHARGE:

I HAVE ANSWERED THE ABOVE QUESTIONS TRUTHFULLY TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE THE PROGRAM TO OBTAIN A CRIMINAL HISTORY, AND IN ACCORDANCE WITH THE FAIR CREDIT REPORTING ACT, TO RELEASE ANY INFORMATION OBTAINED TO THE CLINICAL AND INTERNSHIP AFFILIATES IF REQUESTED. 

I, myself, completed this form and submitted it  for review.  Place your initials here: