The House Where Jesus Shines will only accept applications from men on parole, probation, out of county jail, or state jail. Family or friends request will be discaded. Each man must demostrate a desire to come to the house and to comply with the program's requirements to be considered.

Any untruth given will automatically disqualify you from this program.

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.

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?

Branch?

Years in Service?

Start Date?

Ending Date?

War Zone?

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?

Yes
No

Is electronic monitoring a requirement of your parole?

Yes
No

Are you a registered sex offender?

Yes
No

Are you HIV positive?

Yes
No

Last Name

First Name

Middle Name

Address

City

State

Zip Code

Emergency Contact (Name/Address/Phone Number)

Identification Type and Number (TDC#) or (ISF#)

Social Security Number

Sex

Age

Date of Birth

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.

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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.

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