MM Addendum to Application Complete this form only after you have filled out our main application. This attachment is designed to meet the requirements of "Screening and Eviction for Drug UAbuse and Other Criminal Activity: Final Rule Name* First Last Email* Phone*Have you, or a member of your household, been evicted from federally assisted housing for drug related criminal activity in the past 3 years?* Yes No If Yes, Please explain*Have you, or a member of your household, been convicted of a drug related criminal activity on the premises of federally assisted housing?* Yes No If Yes, Please explain:*Are you, or a member of your household, currently engaged in the illegal use of alcohol and/or drugs?* Yes No If yes, explain:*Are you, or a family member, subject to lifetime registration as a sex offender under a State Registration Program 982.553(a)?* Yes No If Yes, Please explain:*Please Check the Appropriate ResponseAre you, or a family member, currently engaged in, or has engaged in during a reasonable time before admission:Drug-related criminal activity?* Yes No Violent criminal activity?* Yes No Other criminal activity, which may threaten the health, safety or right to peaceful enjoyment of the premises by other residents or persons residing in the immediate vicinity?* Yes No Other criminal activity that would threaten the health or safety of the owner, staff, contractor or subcontractor?* Yes No If yes to A, B, C or D above, please explain:Head of Household* Male Female National Origin* Black White Asian Native American Alaskan Native Pacific Islander Ethnicity* Hispanic Non-Hispanic Other Adult member of the household Male Female National Origin* Black White Asian Native American Alaskan Native Pacific Islander Ethnicity* Hispanic Non-Hispanic Signature Authorization* I agree that I've answered truthfully and to the best of my ability. Clicking on the registration button carries the same weight as signature. NameThis field is for validation purposes and should be left unchanged.