Housing Application

Please fill out the following application.  If you would like to fill it out manually you can download from our forms section in the media center.

Name *
Please add your IDOC, Federal or other State Prison ID #
Sex *
Please add your contact phone #
Please add your contact phone #
Birthdate *
Release Date
Release Date
Do you have a Drivers License or State ID
Do you have a Temporary ID? *
Do you have a Social Security Card?? *
Do you have medical coverage? *
Please describe which ID's and why you haven't applied?
Please enter the facility which you are coming from
Enter what charges in which you were convicted
Parole Discharge Date
Parole Discharge Date
Please enter County, City and State of Birth
Marital Status *
Do you have any children? *
Enter the ages of your kids
Do you pay child support? *
Are you religious?
If you are religious, do you attend church?
Enter Name and City/State
Enter name and City/State
If graduated or GED, please enter approximate date
If graduated or GED, please enter approximate date
Do you plan on continuing your education? *
How long was the longest you were employed? *
Are you a veteran?
Do you have any medical conditions that require doctor's care? *
Would this medical condition prevent you from seeking employment?
Are you currently disabled? *
Do you receive disability benefits?
Have you ever been hospitalized? *
Enter text here
Will you be receiving any financial assistance from family? *
Enter text
Have you ever had a checking/savings account? *
Do you currently owe fines, restitution to any public entity? *
Have you ever been diagnosed with a mental illness? *
Are you under the care of a psychologist or psychiartrist?
Are you currently taking any medicines for your mental illness? *
Do you need to see a counselor or psychiatrist for medication monitoring? *
Have you ever used any of the following: *
Have you ever been in treatment (in or out patient) for substance abuse?
Are you required to register as a sex offender or violent offender to youth? *
Please choose 3-5 positive character traits? *
Please describe the people who will help you emotionally and financially


Our Office

680 Genesee St.
Waukegan, IL, 60085