Please note that no roofing, plumbing, electrical, or foundation projects will be accepted. 1 2 Application Type * Homeowner Organization Renter Refer a Friend/Neighbor Project Site Address * APPLICANT INFORMATION* Person filling out this form First Name * Last Name * Address * City * State * Zip * Phone Number * Email Address When is the best time to reach you? * Day Evening Please list the best day/times to have a Day of Caring representative visit for a project assessment? * Does your organization serve veterans or is anyone residing in the home a veteran? * yes no HOMEOWNER INFORMATION Homeowner Name Homeowner Phone Number RENTAL INFORMATION (if applicable) Landlord Name Landlord Phone Number Renter Name Renter Phone Number Is the landlord aware of this application? Yes No * A landlord's signature is required prior to approval of all applications. ORGANIZATION INFORMATION (If applicable) Organization Name Organization Phone Number PROJECT INFORMATION Project Description * Please be as specific as possible Please list in detail any equipment or supplies you may have or can supply for this project: * How much can you financially contribute toward this project? * $ Is there anything else you would like us to know about this project? REVIEW AND ACKNOWLEDGEMENT I certify that this application was completed by me and that all entries on it and all information in it are TRUE and COMPLETE to the best of my knowledge * Agree This application is not requesting a roofing, plumbing, or foundation project * Agree I understand that an application does NOT guarantee that this project will be accepted * Agree Please provide your digital signature below Full Name * Today's Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 By entering my name below I certify that the information provided in this application is true and complete to the best of my knowledge * Please upload your SIGNED "Project Release of Liability" waiver * Files must be less than 2 MB.Allowed file types: gif jpg jpeg png pdf.
