Today’s Date: ________________

PO Box
Missoula, Montana

406 926 2460

IIMEMAIL2018@GMAIL.COM

Agreement Form
and
Rules and Policy

Call, mail or email all signed forms for pick up arrangements

Please read the entire packet and fully understand the House Rules and
Regulations before you sign and commit yourself to Integrating Integrity of
Montana. We want nothing more than a fully committed person, who wants to
remain clean and sober, while improving themselves and their community.
 Agreement of Residency
To be accepted to our safe and sober home this application must be completed it entirety. Carefully read
and complete all questions to the best of your knowledge. Unanswered questions will not be given
priority in the selection and interview process. If you should need help with understanding with a
question, please as a case worker or others for help.
You will then be contacted by I.I.M for either a telephone or person to person interview. This is an
opportunity to confirm or add-to the information that you have given. This will also be an opportunity for
you to ask any questions that you may have about the organization.

Name: _________________________________ D.O.B: ________________________________

A.O. Number: __________________________ Social Security #: ________________________

Marital Status: Single Married Divorce Separated Children: ________ Ages: _________

Case Manager or P.O. with a good phone #: __________________________________________

Are you on Probation? Y / N Current Charges: _____________________________________

______________________________________________________________________________

Phone number, Time and Where you can be reached for an interview: _____________________

______________________________________________________________________________

Incarceration/Treatment Release Date: ________________ Restrictions: ___________________

Do you have any mental or physical disabilities? Y / N If yes, please explain in detail:
_____________________________________________________________________________

List all medications that you take: __________________________________________________

Clinic and Physician name: ________________________________ Phone #: _______________

In case of Emergency, please provide a name and current phone number: ___________________

______________________________________________________________________________

Any Additional Information: ______________________________________________________

______________________________________________________________________________

Revised: July 2018 2

Provide 3 personal references and relationship:

1st: _______________________________________ Phone #: ___________________________

2nd: ______________________________________ Phone #: ___________________________

3rd: _______________________________________ Phone #: ___________________________

Are you employed? Y / N Employer’s Name: _____________________________________

If you are not currently employed, please provide a summary of how you plan to pay for your
move in expenses and how you plan to get a job: ______________________________________

______________________________________________________________________________

______________________________________________________________________________

Do you own a vehicle? Y / N If yes: Make ___________ Model _________ Year _________

(For a parking space, unauthorized vehicles will be towed at the expense of the registered
owner).

By signing below, I understand and agree to meet the following expectations, if accepted for
residency into Integrating Integrity of Montana (I.I.M)

 I agree to remain clean and sober, at all times. I understand that if I violate this policy I
will be immediately expelled for I.I.M. Initial: ________
 I agree to pay my monthly rental assessment in advance. I understand that if I fail to pay
my rental assessment, I will be expelled for I.I.M. Initial: ________
 I agree to follow the rules and regulations for I.I.M. I understand that if I violate those
agreements, I can be immediately expelled from I.I.M. Initial: ________

I certify that all the information I have provided to Integrating Integrity of Montana is true and
correct.

Signature: ____________________________________ Date: __________________________

Revised: July 2018 3

 1. No drugs or alcohol
House Rules 2. No acts of violence (including threats or intimidation)
3. No underage visitors, unless they are your children: No
babysitting on property.
4. Visitors must be screened, be scheduled, and not be left unattended
5. No overnight visitors, including your children
6. No excessive noise after 9:00 pm, before 8am
7. No chemicals, candles in the house
8. No weapons of any kind allowed on the property
9. You must do your share of housekeeping/ chores
 You must clean your dishes after each meal or snacks, rooms must be tidy, and bed
made daily, do your share and be respectful
 Additional list will be given or posted, if needed
10. No nails or tapes on the walls
11. You are not permitted in other tenant’s room without their permission or a knock
12. Store items in designated areas only
13. No unauthorized or personal locks on bedroom doors
14. No Air Conditioning Unit, other than a fan, without prior approval
15. House curfew in from 10:00 pm until 6:00 am
16. No smoking or vaping in the house
17. Medication must be stored in a locked box, that I.I.M is able to access
18. Must be willing to submit to a random drug and alcohol screening, at your expense
19. Attending AA/ NA or other support groups are encouraged
20. No tampering with housing wiring, ventilation or utilities
21. Provide a YOUR cellphone number & email, upon activation
22. Provide your current Driver’s license, Registration and Proof of Insurance for a parking
space (this applies toward borrowed vehicles).
23. Clean your room after you vacate: sweep and wipe down surfaces.

Revised: July 2018 4

 1. Rent must be paid in full before or on the first of every month to
House Policy avoid a late fee, unless prior payment arranges are made. Failure
to pay rent on time and in full will result in a late fee of $5.00 per
day. Failure to pay the full balance owed after 10 days will result in eviction.

2. Payment will be in a money order, cashier’s check, or cash. No Personal checks will be
accepted.

3. Be respectful, helpful, honest and do not cause disruption to the sensitive sober living
environment.

4. Belongs left behind after exiting the premises, will be donated after 30 days.

5. Transitional Living residents will only be given necessary equipment to comply with
restriction, i.e.: Telephone for monitoring purposes.

6. If needed, we will contact your P.O./Case Manager or other listed persons to inquire about
sobriety concerns.

7. As this is Temporary Living, filling your rooms with only necessary belongs.

8. Make yourself available for house meeting.

9. Inspections of rooms and shared living areas will be inspected, and "To-Do" listed item(s)
need to be done immediately.

10. Residences are asked to make attempts to seek permanent housing away from I.I.M to
transition within a 4 to 6-month time-period. I am willing to assist with this process, if needed.

11. Application, Rules and Policy are subject to changes, to protect all involved parties. Notice
of changes will be posted for all to view.

12. Grievances should be submitted in writing to iimemail2018@gmail.com or mailed.

Name: _______________________________________ Date: ___________________________

Rates 14th Street/Mount Street O’Keefe

Non-Refundable Move In Fee: 300.00 300.00
Monthly Rent 550.00 550.00

Revised: July 2018 5

FOR OFFICE USE ONLY: IIM NOTES REJECTED / ACCEPTED

Placement: __________________________________________________________________

Why? _______________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Restriction? ___________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Notes about the applicant: ________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Additional Info: ________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Contact for further information: ___________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Revised: July 2018 6