Homeownership Program Interest Form

1. Please provide each of the following:

Please provide each of the following: Name:
Home Address:
Home Address 2:
City:
State:
ZIP:
Email Address:
Phone Number:

2. Please answer the following (if applicable):

Please answer the following (if applicable): Employer Name:
Employer Address:
Employer Address 2:
City:
State:
ZIP:

3. Has anyone in your household ever served in any branch of the United States military, or not?

Has anyone in your household ever served in any branch of the United States military, or not? Yes, someone has

No, no one has

Not sure

Other (please specify)

4. Is anyone in your household currently serving in the United States military, or not?

Is anyone in your household currently serving in the United States military, or not? Yes, someone is

No, no one is

5. Is anyone in your household a widow of a former veteran, or not?

Is anyone in your household a widow of a former veteran, or not? Yes, someone is

No, no one is

6. Is anyone in your household a senior citizen?

Is anyone in your household a senior citizen? Yes, someone is

No, no one is

7. Are you or is anyone in your household physically, mentally, or emotionally disabled?

Are you or is anyone in your household physically, mentally, or emotionally disabled? Yes, someone is

No, no one is

8. How did you hear about our program?

How did you hear about our program? Church

City Hall

Community/Civic Group

Family/Friend

Habitat Homeowner

Habitat Outreach/Event

Habitat Website

Habitat Offices/ReStores

Habitat Speakers Bureau Presentation

Internet/General Web Search

School

Television

Radio

Newspaper

Work/Job Fair

Check out our sample surveys and create your own now!

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