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 PhoneCell PhoneWork PhoneBest number to call during the day Home Phone Cell Phone Work Phone Housing SituationCurrent 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 & ServiceHow 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* 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 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 MM slash DD slash YYYY 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 PhoneEmail Mailing AddressOther 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. CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
Serving Vermonters since 1982
Serving Vermonters since 1982