Prison Ministry - Application Name* First Middle Last Maiden/Alias Name Date of Birth mm/dd/yyyy* Place of Birth* City and StateAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County* Last Four SSN#* Driver's License #* State License was Issued* Gender*MaleFemaleThird ChoiceRace* Age* Current Occupation* Email* Phone*State of Ohio User ID Number This only applies to State of Ohio employeesYour Last 5 Years of Residency - City/State/Zip and # of yearsPlease provide 3 personal and/or professional references - Name/Relation/Home or Work Number*Please List 3 Emergency Contacts*Name/Relation/Number/Address-City,State,ZipFamily doctor or hospital to contact* Do you wear a medical tag? If yes, talk to Marty!* Yes No You would know what it is if you wear one.What is your highest level of education?* Please provide your car model and plate numbers* Preferred institution to serve?* Lebanon (men's) Warren (men's) Dayton (women's) Background InformationHave you ever been employed by the Department of Rehabilitation and Correction? If yes, where?* Have you ever been a temporary employee, volunteer or intern for the Department of Rehabilitation and Corrections? If yes, where?* Have you ever been dismissed from any organization as a volunteer/intern? If yes, talk to Marty.* Yes No Criminal HistoryHave you ever been convicted of a criminal offense? If yes, talk to Marty.* Yes No Have you ever been incarcerated? If yes, talk to Marty.* Yes No Are you currently on probation with any city, county or state law enforcement? If yes, talk to Marty.* Yes No Are you related to or associated with any offender presently incarcerated or under the supervision of the Ohio Department of Rehabilitation and Correction? If yes, talk to Marty* Yes No Have you ever been a victim of a crime? If so, what type?* NexusAre you related to or do you know anyone in the prisons? If yes, talk to Marty.* Yes No
