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Before filling this
application, please make sure that you have reviewed all of the Eligibility
Rules.
You
may also fill out this application
online for immediate consideration.
Click here
for a printable application form.
Application for Residence with H.O.M.S
Full Legal Name: ____________________________________
Muslim Name: ______________________________________
Social Security: _____________________________________
Drivers License: ____________________________________
INS Status (If Applicable): _____________________________
Former Address: ____________________________________
Prior Address (If Less then 2yrs): ________________________
General Information
Mother's Name: _____________________________________
Phone & Address: ___________________________________
Father's Name: _____________________________________
Phone & Address: ___________________________________
Marital Status: ______________________________________
Husband's Name (If Applicable): ________________________
Phone & Address: ___________________________________
Present Employer: ___________________________________
Phone & Address: ___________________________________
Please List 3 Personal References with Phone Numbers
1._____________________________________________
2._____________________________________________
3._____________________________________________
Background Investigation Inquiry Release
In connection with my application with H.O.M.S, I understand that investigative background inquiries are made on myself including criminal and other reports. I understand that H.O.M.S will be requesting
information from various federal, state and other agencies which maintain records concerning my
background as it pertains to criminal activity. I authorize, without reservation, any party or agency
contacted by this organization to furnish the above mentioned information and hereby release. and agree
to hold harmless and/or to indemnify, this organization and any party or agency providing such information, from any and all liability arising from the request of, use of, or furnishing of such information.
If you will be driving a facility vehicle please fill in driver’s license number and the state in which the
license is issued.
(Print) First Middle Last Name
Muslim Name
Social Security Date of Birth
Address (No P.O.Boxes)
City State Zip Code
List each city and state you have lived and worked in during the following years:
CITY STATE JOBS ZIP CODE
1999 __________ __________ ___________ _________
1998 __________ __________ ___________ _________
1997 __________ __________ ___________ _________
1996 __________ __________ ___________ _________
1995 __________ __________ ___________ _________
Have you ever been convicted of a crime other than a misdemeanor traffic violation?
(Convictions will not necessarily disqualify applicant)
If yes, Please provide name of offense and city or state which the offense occurred.
If yes explain:
Future Revisions and Additions to Household Guidelines Clause:
The H.O.M.S. board reserves the right to make any revision or addition to the H.O.M.S. Household Guidelines at any time.
In addition, residents must comply with any new program or guideline that is approved
by the H.O.M.S. board and is added to the aforementioned household guidelines.
I acknowledge that I have read the H.O.M.S. Household Guidelines completely, and I understand the terms of my residence. I also acknowledge that I have received a
personal copy of the Household Guidelines Handbook.
Resident's Signature: ______________________________________
Date:
___________________________________________________
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