HomeShare Vermont Application

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.


Complete if you want to share your home:

*Denotes required field

*How did you hear about HomeShare Vermont?

*Have you had any past association with HomeShare Vermont?  Yes No


*First name: *Last name:

Other names used:

*Mailing address:

*City: *State: *Zip:

Physical address (if different):

Email:

Home phone:

Cell phone:

Work phone:

Best number to call during the day:


Housing Situation

*Current housing situation:

If other, please explain:

If renting, Landlord's name: Phone:

*How long at current address? Since (mo/yr): /

What pets do you have?

If a dog, has it ever bitten anyone?


Rent & Service

How much rent would you charge? $/month  Not sure

Hours of service you need: hours/week  Not sure


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:

*DOB M/D/Y: //

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?

First name: Last name:

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:

DOB M/D/Y: //

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


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 reference should cover a span of at least 5 years to the present. Please notify your references that HomeShare Vermont will be calling them.

  1. *Reference 1 name:
    *Daytime phone:
    *City *State:
    Email:
    *How long have they known you?
    *How do they know you?
  2. *Reference 2 name:
    *Daytime phone:
    *City *State:
    Email:
    *How long have they known you?
    *How do they know you?
  3. *Reference 3 name:
    *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:
Relationship to applicant:
Phone:
Email:
Mailing address:


Other information you want us to know:


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.



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