NEW MEMBERSHIP:

HOPATCONG HELPING HANDS APPLICATION FORM

(Highlight, Copy, and Paste to a Word Document or Email Program for Approval)

Co-Sponsored by:

Hopatcong Borough Mayor, Council, and the Board of Education

NAME:_____________________________________________

ADDRESS:__________________________________________

PHONE NUMBER:____________________________________

How long at current residence? _____--Years

If less than ten (10) years list previous address and how long there:

________________________________________________________

Date of Birth: Place of Birth:____________

Your Social Security Number________________________________

Marital Status: Married______ Divorced______Single______

If married, list name of Spouse and Social Security number:

_______________________________________________________

If there are any other adults living in your home please list their names and Social Security Numbers:_______________________________________

Have you ever been convicted of a crime? Yes____ No____

If yes, please explain the nature and location of conviction below:

_____________________________________________________________

Has anyone in your residence ever been convicted of a crime?

If yes, explain the nature and location of the conviction below:

_____________________________________________________________

List all residents including minor children currently living with you not listed previously.

Name____________ Date of Birth_________ SS#___________

I_________________ represent that all the above information is true and correct and that any misinformation will automatically void this application.

I understand that this is an application for becoming a "Safe House" in the Hopatcong Helping Hands Program. I also understand that I and/ or my spouse and anyone living within my residence will be legally investigated for any criminal record.

I have received a copy of the Hopatcong Helping Hands Guidelines and understand them.

By signing this application, I hereby grant permission to the /PoliceDept/hbpdsite/hbpdpage1 to do a criminal record check on the persons listed herein.

Signature___________________ Date_____________

Approved___________________ Date_____________

Chief of Police

Hopatcong, N J

For paper application form or more information call Tom Kuty @ 973-398-0676 or

email to tomkuty@blast.net or

mail to 141 Madison Trail or

click on "Safe House" email link below

Hopatcong Borough Mayor, Council, and the Board of Education

Date of Birth:__________ Place of Birth:______________________

Date of Birth: Place of Birth:____________