Application for Membership Next Step
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name 
(First , last)
Present Address
(complete with city , state , zip)
Date of Birth
MM
/
DD
/
YYYY
Phone where you can be reached
E-mail ?
Are you an Alcoholic ?
Date of your last Drink?
MM
/
DD
/
YYYY
Are you addicted to Drugs ?
Clear selection
Date of last Drug use
MM
/
DD
/
YYYY
List Drugs you used addictively :
When did you first attend your first AA or NA meeting ?
MM
/
DD
/
YYYY
How many AA / NA meetings do you now attend each week ?
Do you want to stop drinking alcohol and using addictive drugs ?
Clear selection
Are you employed 
Clear selection
Who is your employer ? 
Only if you chose yes to the above question 
Are you getting welfare or other(Disability)  non-job related income?
If yes type what type of income under "Other"
Clear selection
If you do not have a job will you get one ?
Describe below
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If yes to above question , then what plans do you have for working ?
What is your monthly income right now ?
What do you expect your monthly income to be next month ?
Marital Status ?
Clear selection
Do you have a medical Doctor?
Clear selection
List the Doctors Names and phone numbers 
Have you ever been to a treatment facility for alcoholism and or drug addiction?
Clear selection
If yes to Above .. List the treatment providers, phone numbers and primary counselor, if any. 
Do you take prescription Drugs?
Clear selection
If yes to above list Drugs and reason the drug has been prescribed.
Date of Move in ?
If "other" list the date you would want to move in, if accepted , and why the date is in the future rather than immdedietly ..
Date of move in
MM
/
DD
/
YYYY
Have you ever lived in a Sober Living House before ?
Clear selection
If Yes , provide the name and location of the house below
If yes, you left the previous Sober House for the fallowing reasons :
For other type in the reasons
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Do you Currently Owe Money to any sober House ?
Clear selection
If you do owe money , I will agree to repay the money i owed to my former Sober house 
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Emergency Contacts
 Name & phone number or address
Emergency contact Person 1
Type of relationship
Emergency contact Person 1
Name & phone number 
Emergency contact Person 2
Type of relationship
Emergency contact Person 2
I realize that Next step is a self run oxford house to which i am applying for residency has been established in compliance with the conditions of $2036 of the Federal Anti-Drug Abuse act of 1988, P.I..100-690, as amended , which provides that federal money loaned to start the house requires the house residents to (a) prohibit residence from using any alcoholic or illegal drugs, (B) expel any residents who violates such prohibitions. (C) Equally share household expenses including the monthly lease payment, among all residents and utilize democratic decision making within the group including inclusion in and expulsion from the group. BY ACCEPTING THESE TERMS, THE APPLICANT EXCLUDES HIMSELF OR HERSELF FROM THE NORMAL DUE PROCESS AFFORDED BY THE LOCAL LANDLORD-TENANT LAWS.
Clear selection
use this space for additional relevant information 
I have read all of the material on this Digital Appilcation form including the limitations set forth in items above and have honestly answered each question and want to achieve a comfortable recovery from alcohol or drug addiction without relapse .
Submit
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