Family Living Application

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Social Security Number:

Date of Birth

Place of Birth (City, State)

Email Address

Name and Date of Birth of all Individuals Residing in the Home:

Name

Date of Birth

Name of ALL Adult Children In/Out of the Home:

Name

Employment History:

Name of Employer

Start Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisor's Name

First Last

Type of Business

Name of Employer # 2

Start Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisor's Name

First Last

Type of Business

Personal References; Please list three non-related persons

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Family Living Support Provider shall furnish to ADID Care, INC, with the following information:

Proof of U.S. Citizenship
Drivers License
Proof of vehicle registration and insurance
Homeowners Insurance

The Family Living Support Provider will Notify ADID Care, INC in writing at least 30 days in advance of cancellation or any changes.

Initials:

Family Living Provider herby authorizes and gives permission to ADID Care, INC> to secure the following information:

Permission to obtain reference information by mail, telephone, or in a home visit.
Authorizes verification of military history, employment, and marriages
Authorizes verification of medical records
Authorizes permission to obtain copies of public records screens and FBI criminal records screening

Initials

The Family Living Provider ( herein "Applicant") agrees to the laws and regulations applying ot the Applicant and providers. Applicant understands that there is no guarantee of placement in the home by completing this application. Applicant agrees to follow ALL ADID Care, INC polices and procedures AND DD Waiver Standards. Applicant certifies that all the information provided in this application is accurate.

Applicant Signature

03/21/2023