Please tell us about yourself, your household, and your dwelling.

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* 1. First Name

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* 2. Last Name

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* 3. Phone number

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* 4. Email address

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* 5. Date of Birth

Date

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* 6. Please choose the description that best matches you:

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* 7. Street Address

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* 8. City

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* 9. State

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* 10. Zip Code

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* 11. County of Residence

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* 12. How did you hear about Host Services?

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* 13. Do you have previous Host experience? If so, what agency?

Please describe your home:    

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* 14. Type of dwelling:

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* 15. Special features (pool, play gym, handicapped features, etc):

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* 16. Number of floors

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* 17. Is your home handicapped accessible?

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* 18. Number of Bedrooms (note: host home clients cannot reside in a basement):

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* 19. Number of bathrooms

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