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Application for Membership in Oxford House
Have you applied here before?
If so enter your previous application ID and password to bring up your application.
Email Address
Email Address
required
Please enter a valid email address.
Applicant Password
required
Password must be at least six characters.
Confirm Password
required
Passwords do not match.
Personal Info
Print Name (First, Middle, Last)
required
Name is required.
Present address (Street) Check if treatment facility
City
State
Zip
Date of Birth
Month
Day
Year
Phone Where You Can Be Reached
Home or Cell
required
Please enter a valid phone number.
Work
History
Are you an Alcoholic?
Yes
No
Date of Your Last Drink?
Are you addicted to drugs?
Yes
No
Date of last drug use?
List drugs you used addictively:
When did you attend your first AA or NA meeting?
How many AA/NA meeting do you now attend each week?
Do you want to stop drinking alcohol and using addictive drugs?
Yes
No
Employment
Are you employed?
Yes
No
If “yes” who is your employer?
Are you getting welfare or other non-job related income?
Yes
No
If “yes” what?
If you do not have a job will you get one?
Yes
No
If “yes,” what job plans do you have?
What is your monthly income right now?
What do you expect your monthly income to be next month?
Marital Status
Married
Never Married
Separated
Divorced
Medical Info
Do you have a medical doctor?
Yes
No
If “yes” list the doctor’s name and phone number:
Have you ever been to a treatment facility for alcoholism and/or drug addiction?
Yes
No
If “yes” list the treatment provider, phone number and primary counselor, if any.
Do you take prescription drugs?
Yes
No
If “yes” list drugs prescribed.
Move-in Info
Date of move in?
Immediately
Other
If “other” list the date you would want to move in, if accepted.
Why is the date is in the future rather than immediately?
Have you ever lived in an Oxford House before?
Yes
No
If “yes,” provide the name and location of the Oxford House below.
I left the previous Oxford House for the following reason:
Relapse
Voluntarily
Other reason(s)
I owe money to the Oxford House I left.
Yes
No
If I do owe money to the Oxford House I left, I will agree to repay the money I owe to my former Oxford House.
Yes
No
Emergency Contact
Name and Address
Relationship
Telephone
Additional Information
Use this space for additional relevant information:
Where are you looking for a house?
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GH
HI
IA
ID
IL
IN
KS
KY
LA
MD
ME
MI
MN
MO
MS
MT
NC
NE
NJ
NM
NY
OH
OK
OR
PA
RI
SC
SD
TN
TS
TX
VA
VT
WA
WI
WV
WY
County
Gender
Male
Female
I realize that the 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.L. 100-690, as amended, which provides that federal money loaned to start the house requires the house residents to (A) prohibit all residents from using any alcohol or illegal drugs, (B) expel any resident who violates such prohibition, (C) equally share household expenses including the monthly lease payment, among all residents, and (D) utilize democratic decision making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant understands that §2036 conditions are different than the normal due process afforded by some local landlord-tenant laws. I have read all of the material on this application form including the limitations set forth. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse.