REMODEL FOR LIFE, LLC
MN Building Contractor License #BC724661. UMPI #A509145000.
Helping Professionals, we accept all MN DHS Waiver Programs and VA Programs. Please use this form to request an estimate for a Environmental Accessibility Adaptation home modification project. One of our certified professionals will be in touch within ten (10) business days of submission.
Requestor's Information
Please provide us with information about yourself
Requestor Name
*
First Name
Last Name
Requestor Email
*
example@example.com
Requestor Phone
*
Please enter a valid phone number.
Requestor Organization
*
County Name, Assessments Service, Etc.
Relationship to Client
Please Select
Parent/Legal Guardian
Case Manager/Social Worker
Occupational Therapist
Doctor
Other
Client Information
Please provide us information about the client
Client Name
*
First Name
Last Name
Client Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Phone
Please enter a valid phone number.
Client Email (if applicable)
example@example.com
Is there an onsite contact?
*
Please Select
Yes
No
Onsite Contact Name
First Name
Last Name
Onsite Contact Phone Number
Please enter a valid phone number.
Please provide us with a brief description of the project.
Submit
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