Service Application Your Name (required) Your Email (required) Address (required) Gender (required) MaleFemaleGender neutral Cell Phone (required) Other Phone Marital Status YesNo Name and contact information for someone who will always know your whereabouts Current status: (If you don’t have a criminal record, please skip to the Employment and Education section) Have you ever been in jail or in prison? YesNo Are you currently on probation/parole? YesNo If you were in jail or prison, when was your date of release? Are you listed as a felon? YesNo Where did you serve your time? How long did you serve your time? Which of the brought you to LIFE of NC by? Judge requiredCondition of probation/paroleRecommended byOther Employment and Education Did you graduate High School? YesNo If no, last grade completed. Do you have any college of trade school experience? YesNo If yes, where? Did you graduate? YesNo When did you graduate? Are you currently employed? YesNo If yes, where? Since when? Dependencies Do you currently have a drug or alcohol use problem? YesNo If yes, have you ever been in treatment? YesNo
