Recovery Residence Application

Recovery Residence

MM slash DD slash YYYY

Employment Status


Substance Use & Treatment


MM slash DD slash YYYY
I hereby authorize Jeremiah's House and its designated agents and representatives to conduct a review of my background. I understand that the scope of this background check may include, but is not limited to the following: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, medical records from a treatment facility, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records. I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to or its agents.
This field is for validation purposes and should be left unchanged.