1.  Tell Me About Yourself:

  -When Is Your Birthday?  ____________________


  -How Long Have You Lived At Your Present Location?____________________


  -Do You Own Or Rent Your Home?_____________________________________


  -Are You Willing To Relocate If Need Be?_______________________________


  -What Do You Do For A Living?________________________________________


  -How Long Have You Been Working At Your Present Employer?_____________________


Maritial Information...

  __________Married?   If Your Answer Was "Yes", What Is Your Situation At The Present Time?


  -Legally Seperated____________


  -Living Apart Only____________


Please Explain:_______________________________________________________________________
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  -Do You Have Any Children?_____________________________________


Please Explain:_______________________________________________________________________
____________________________________________________________________________________________
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  -DoYou Have Custody Of Your Children?_____________________________________________


Please Explain:_______________________________________________________________________
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  -Do You Desire To Have Children?   ______________________________________

Health Information...

  -Current Medical Conditions You Are Presently Under A Physicians Care For?

_______________________________________________________________________________________
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  -How Often Do You See Your Physician?_____________________________________________


  -Current Prescriptions You Are Currently Taking?

_____________________________________  ________________________________________________
_____________________________________  ________________________________________________
_____________________________________  ________________________________________________
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  -Do You Have Any Physical Or Emotional Disabilities?   __________________________


  -Have You Ever Been In A Drug Or Alcohol ReHab Program? _________________________________


  -Are You Active Now In Any Illegal Drug Usage? _________________________________


If Your Answer Was "Yes" Please Explain:   ____________________________________
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____________________________________________________________________________________________


  -Do You Consume Alcohol Beverages?   __________________________________


Please Explain:_______________________________________________________________________
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  -Do You Smoke Cigarettes Or Cigars?   ____________________________________

Crimminal History:

  -Have You Ever Been Arrested?   ___________________________________


  -Have You Ever Served A Sentence In A State Or Federal Prison?  ________________


Please Explain:_______________________________________________________________________
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____________________________________________________________________________________________
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  -Are You Currently On Supervised Probation?   ____________________________


  -Have You Ever Been Charged With A DWI Or DUI?   _______________________


Please Explain:_______________________________________________________________________
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