CompanyThis field is for validation purposes and should be left unchanged.Note: 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 for that person as well. If you have any questions, please feel free to call our office at (802) 863-5625. Your Information * Denotes required fieldFull legal name (First, Middle, Last):* First Middle Last Other names used:Preferred pronouns: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: Home Phone Cell Phone Work Phone How did you hear about HomeShare Vermont?*Have you had any past association with HomeShare Vermont?* Yes No Please be aware that there are typically 4 times the amount of people looking for housing as there are homes available and we cannot guarantee that everyone will find housing through our program.Number of people seeking housing together:*123456789Date housing needed:* MM slash DD slash YYYY Please indicate your location preference:* Greater Burlington Area Rural Chittenden County Addison County Grand Isle County Franklin County Lamoille County Orange County Washington County Windsor County Craftsbury/Greensboro/Hardwick Brandon/Killington/Pittsfield No Preference NOTE: If you are interested in homesharing outside our coverage area, please see our Resources page.I will only consider these towns:What is the maximum rent per month you would pay?What is the maximum number of hours of service per week you can provide?What pets do you have?If a dog, has it ever bitten anyone? Yes No The following factors will help us better understand your housing needs. Please check the box if the statement applies to you. I have a car and can drive I can drive but don't have a car I need to be near a bus line I am a smoker Housing HistoryCurrent housing situation:* Rent Own If other please explain.How long at current address?From:* MM slash DD slash YYYY To:* MM slash DD slash YYYY If renting, current landlord's name and number:Previous housing situation:* Rent Own If other please explain.How long at previous address?From:* MM slash DD slash YYYY To:* MM slash DD slash YYYY Address:*City:*State:*If renting, previous landlord's name and number: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* MM slash DD slash YYYY 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 Annual gross household income (Must include all sources of income):*If we are successful in matching you, there is a one-time, income-based match fee starting at $60 on a sliding scale. If fees are a hardship, fees can be adjusted or payment plans can be arranged.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 Have you ever been evicted?* Yes No If yes to any of these questions, please explain:Employment HistoryCurrent employment status:* Full time Part time Retired Unemployed Student Current Employer:Position/Title:City:State:Date of hire MM slash DD slash YYYY Previous Employer:*Status: Part time Full time Position/Title:Dates employed:From: MM slash DD slash YYYY To: MM slash DD slash YYYY City:State:References: All references should be people who have known you at least 1 year. Together, the references should cover a span of at least 5 years to the present. We require references from past or present roommates, employers or co-workers. NOT ACCEPTED as references are family members or romantic partners. It is essential that you notify your references that HomeShare Vermont will be calling them. Please realize that if you have trouble reaching them, we will also have the same trouble, and your application will be delayed.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?*Reference 4 Name:* First Last Daytime Phone*City:*State:*Email How long have they known you?*How do they know you?*Other information you want us to know:Is there another adult seeking housing with you? Yes No Second Adult InformationName: First Last 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: Home Phone Cell Phone Work Phone Housing HistoryCurrent housing situation: Rent Own If other please explain.How long at current address?Current Landlord's name:Landlord's phone:Previous housing situation: Rent Own If other please explain.How long at this address?Address:City:State:Previous landlord's name:Previous landlord's phone: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.GenderDate of birth MM slash DD slash YYYY AgeEthnicity Hispanic Not Hispanic Ethnicity White Black/African American Asian American Indian/Alaskan Native Nat. Hawaiian/Other Pacific Islander Do you have a disability? Yes No Do you receive Medicaid? Yes No Annual gross incomeMust include all sources of incomeAs 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 Have you ever been evicted? Yes No If yes to any of these questions, please explain:Employment HistoryCurrent employment status: Full time Part time Retired Unemployed Student Current Employer:Position/title:City:State:Previous employer:Status Part time Full time Position/titleCity:State:All references should be people who have known you at least 1 year. Together, the references should cover a span of at least 5 years to the present. We require references from past or present roommates, employers or co-workers. NOT ACCEPTED as references are family members, friends or romantic partners. It is essential that you notify your references that HomeShare Vermont will be calling them. Please realize that if you have trouble reaching them, we will also have the same trouble, and your application will be delayed.Reference 1 Name:Daytime phone:City:State:Email: How long have they known you?:How do they know you?:Reference 2 Name:Daytime phone:City:State:Email: How long have they known you?How do they know you?Reference 3 Name:Daytime phone:City:State:Email: How long have they known you?How do they know you?Reference 4 Name:Daytime phone:City:State:Email: How long have they known you?How do they know you?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 Section BreakCAPTCHA
Serving Vermonters since 1982
Serving Vermonters since 1982