Name
*
First Name
Last Name
Inmate No. or CID No.
*
Why do you feel you would be a good candidate for the House Where Jesus Shines program?
*
If you have already received Jesus as your Savior, please give a testimony of how you came to know Him. If there has been a rededication, tell us about that also.
*
Testimony
List people to contact as personal references on your behalf.
If married, why are you not returning to your spouse?
Do you owe child support?
Yes
No
If yes, how much?
Do you owe household or spousal support?
Yes
No
List all immediate family members and ages (wife and children).
List all job skills you possess and years of experience.
List educational or job training experiences while in TDC.
Military Service?
Yes
No
Branch
Years In Service?
Start Date
MM
DD
YYYY
End Date
MM
DD
YYYY
War Zone?
Yes
No
List the offences, how many times you have been in TDC or other facilities, and amount of time spent in each one. (For serious offenses, please explain circumstances)
List any medications you are presently taking and the reason.
List any limitations, physical or other that may keep you from obtaining and maintaining full-time employment (which is a requirement for residency at the House Where Jesus Shines).
Are you being released on parole or probation?
*
Is electronic monitoring a requirement of your parole?
Are you a registered sex offender?
*
Yes
No
Are you HIV positive?
*
Last Name
First Name
Middle Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Emergency Contact (Name/Address/Phone Number)
Identification Type and Number (TDC#) or (ISF#)
Sex
*
Male
Female
Age
*
Date of Birth
MM
DD
YYYY
Marital Status
Referred By
I am voluntarily applying to the House Where Jesus Shines. I do hereby indemnify and hold harmless the House Where Jesus Shines, including its officers, directors, or agents on behalf of the House Where Jesus Shines, from any and all claims, demands, actions, and suits, resulting from any physical injury, property damages, or other personal loss which I may incur as a result of my residency at the House Where Jesus Shines. I understand that if I become more than one week delinquent in paying the program fee, the House Where Jesus Shines has the right to terminate and remove me from the program and remove me from the premises. I give permission for the House Where Jesus Shines to request a criminal history record from all law enforcement agencies. I give permission for the House Where Jesus Shines to request a criminal history record from all law enforcement agencies. I promise that I will cooperate with the rules, regulations, guidelines and policies of the House Where Jesus Shines and will participate in the activities of the House Where Jesus Shines, which have been provided for my benefit. I have read all the above questions, statements and agreements and fully understand them and willingly submit this Application for Residency knowing what I am doing.
*
Authorize Criminal History Record Request
Cancel Application
Due to Texas Identification restrictions any parolees born out of state must send a copy of birth certificate before your application can be accepted. All questions must be answered or your application cannot be processed.
*
