Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Home Phone Number

(###)

###

####

Birthday

MM

DD

YYYY

The best way to contact me is by:

Email

Cell Phone

Home Phone

Name of Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number: *

(###)

###

####

Are you currently employed? *

Yes

No

Highest Level of Education Attained: (MUST HAVE ATTAINED A HIGH SCHOOL DIPLOMA OR G.E.D. EQUIVALENT) *

Some high school

G.E.D.

High School Diploma

Some College

Associates Degree

4-Year Degree

Masters Degree

Have you ever been convicted of a felony offense?

Yes

No

How did you hear about us? *

(select all that apply)

Facebook Ad

Facebook Page

Twitter Feed

Website

Google+ Page

Google Ad

Newspaper Ad

Flint Journal

Grand Blanc View

TV

Open House

Craigslist

Friend

Other