Please fill out the form below with as much honesty & detail as possible, so we can best assess the situation. DGH asks that the below application be fillied out by those responsible for the residence. Serious inquiries only, please.

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Personal Information
First Name:		Last Name:
Email Address:		Phone Number:
Address:		City:
Address (cont.):		State:	--Select One-- Delaware Maryland New Jersey Pennsylvania Virginia
Zip Code
Best Contact	Phone   Email	Time to Contact
Location Information
# of Occupants:
Names & Ages of Occupants (Including yourself)
Occupant #1:		Age:
Occupant #2:		Age:
Occupant #3:		Age:
Occupant #4:		Age:
Occupant #5:		Age:
Occupant #6:		Age:
Age of the Location:	years old
# of Previous Owners:		# of Rooms:
Any recent remodeling done to the location?		No   Minor   Major
Any electrical appliance issues?		No   Yes   Not Sure
Any plumbing issues?		No   Yes   Not Sure
Any occupants having trouble sleeping?		No   Yes   Not Sure
Any occupants having nightmares regularly?		No   Yes   Not Sure
Any occupants involved with the occult?		No   Yes   Not Sure
Has the location been blessed?		No   Yes   Not Sure
History of Site, if Any: (tragedy, death, previous complaints, etc)
Activity Information
Do the occupants agree on what is happening?		No   Yes   Not Sure
Any other witnesses (excluding occupants)?		No   Yes   Not Sure
Any unexplainable odors?		No   Yes   Not Sure
Any unexplainable sounds?		No   Yes   Not Sure
Any unexplainable voices?		No   Yes   Not Sure
Any movement of objects?		No   Yes   Not Sure
Any levitation of objects?		No   Yes   Not Sure
Any physical attacks?		No   Yes   Not Sure
Are your pets affected?		No   Yes   Not Sure
Do any occupants feel threatened? Who?
When was the first occurrence of phenomena? What happened?
How long was the duration of the phenomena?
Anything other information or anything on which you wish to elaborate?