P & P Recovery House

P.O. Box 4084, Virginia Beach, VA 23454

Ph. 757-752-2070

[email protected]

Application for Residency

Full Name__________________________Phone#________________Date_________

Current/Former address________________________ City/State_________________

DOB___________ SSN#______________________ Highest Grade _____________

Driver’s License State/DL#_______________Auto type/Tag#________________

Employer ___________________________________ Weekly income $_____________

Address ____________________________________ How long employed________

Phone _____________________________________________

Supervisor _________________________ any other skills_______________________

Source of income (SSI, Pension, Workman’s Comp, Trust)

History of alcohol/drug abuse yes/no_______ past treatment yes/no_______

Bank Information – Name – Account #- Account Type

Emergency Contact Person/Address/Phone number

Prescription medications:

I authorize Clay Property Management and Consulting, LLC and P & P Recovery Houses, LLC to perform a criminal background check by using the above identification information for the sole purpose of screening for housing. This executed application also gives my permission to coordinate with Federal, State, Local agencies, non-profits, social service agencies to assist in securing housing for me. I further authorize a urinalysis and drug screening. This authorization will remain in effect from the date of this signature until residency is terminated in the premises. I fully understand that if I violate the House Rules or the Lease that I will have a limited time (30 minutes) to vacate the premises and will do so when directed by management.

Printed Name Signature

_________________________ _______________________