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.
*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:
*City: *State: *Zip:
Physical address (if different):
Best number to call during the day: ---HomeCellWork
*Current housing situation: ---RentOwnOther
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? ---YesNo
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.
*DOB M/D/Y: //
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? ---YesNo
First name: Last name:
DOB M/D/Y: //
Do you receive Medicaid? Yes No
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
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.
If completing the application for someone else, please complete below:
Relationship to applicant:
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.