Apply to Share Your Home - Apply

Phone

This field is for validation purposes and should be left unchanged.

Please read through this entire application before you start so that you can gather the information you will need. If there is more than one adult applying to participate in the program we will need information on that person as well. If you have any questions, please feel free to call our office at (802) 863-5625.

Your Information

* Denotes required field.

How did you hear about HomeShare Vermont?*

Have you had any past association with HomeShare Vermont?*

Yes
No

Full legal name (First, Middle, Last):*

First Middle Last

Other names used

Preferred pronouns

Mailing Address*

City*

State*

Zip*

Physical address (if different)

Email

Home Phone

Cell Phone

Work Phone

Best number to call during the day

Home Phone
Cell Phone
Work Phone

Housing Situation

Current housing situation*

Rent
Own

If other, please explain.

If renting, current landlord's name and number:

How long at current address?*

What pets do you have?

If a dog, has it ever bitten anyone?

Yes
No

Rent & Service

How much rent per month would you charge?

Hours of service per week you need?

For reporting and statistical purposes, our funders require that we ask for the following information. This information will help determine that HomeShare Vermont does not discriminate in its services.

Gender

Date of Birth*

Age*

Ethnicity (check one)

Hispanic
Not Hispanic

Race (check all that apply)

White
Black/African American
Asian
American Indian/Alaskan Native
Nat. Hawaiian/Other Pacific Islander
Other Multiracial

Do you have a disability?

Yes
No

Do you receive Medicaid?*

Yes
No

Number of people in household:

Annual gross household income(Must include all sources of income):*

As part of our application process, we do background and reference checks and a personal interview. To begin this process:

Do you have any motor vehicle violations?*

Yes
No

Do you have any pending criminal charges?*

Yes
No

Have you had any criminal convictions?*

Yes
No

If yes to any of these questions, please explain:

Is there a second adult in your household?*

Yes
No

Second adult name

First Last

Other names used

For reporting and statistical purposes, our funders require that we ask for the following information. This information will help determine that HomeShare Vermont does not discriminate in its services.

Gender

Date of Birth

Age

Ethnicity

Hispanic
Not Hispanic

Race (check all that apply)

White
Black/African American
Asian
American Indian/Alaskan Native
Nat. Hawaiian/Other Pacific Islander
Other Multiracial

Do you have a disability?

Yes
No

Do you receive Medicaid?

Yes
No

As part of our application process, we do background and reference checks and a personal interview. To begin this process:

Do you have any motor vehicle violations?

Yes
No

Do you have any pending criminal charges?

Yes
No

Do you have any criminal convictions?

Yes
No

If yes to any of these questions, please explain:

References:

HomeShare Vermont asks for references in order for us to try to find the right person for you. All references should be people who have known you for at least 1 year. Together, the references should cover a span of at least 5 years to the present. Please notify your references that HomeShare Vermont will be calling them.

Reference 1 Name*

First Last

Daytime phone:*

City*

State*

Email

How long have they known you?*

How do they know you?*

Reference 2 Name*

First Last

Daytime phone:*

City*

State*

Email

How long have they known you?*

How do they know you?*

Reference 3 Name*

First Last

Daytime phone:*

City*

State*

Email

How long have they known you?*

How do they know you?*

If completing the application for someone else, please complete below:

Name

First Last

Relationship to Applicant

Phone

Email

Mailing Address

Other information you want us to know:

Please check to continue:*

I hereby acknowledge that all the information I have given in this application is true and complete to the best of my knowledge and belief. I understand that providing any false or misleading information will make me ineligible for the services of HomeShare Vermont.

CAPTCHA