Homeowner Pre-Selection Form

Dear Applicant: We need you to complete this form to determine if you may qualify for the Habitat for Humanity homeownership program. Please fill it out as completely and accurately as possible. All information you include on this form will be kept confidential.

We are pledged to the letter and spirit of U.S. policy for the achievement of equal housing opportunity throughout the nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to obtaining housing because of race, religion, sex, handicap, familiar status or national origin.

Applicant Name*

First name, Last name

Co-Applicant Name

First name, Last name

Primary Phone Number*

Alternative Phone Number

Applicant Email

example@example.com

Co-Applicant Email

example@example.com

Applicant Age*

Co-Applicant Age

Applicant Indicate if Married, Separated or Unmarried**

Unmarried if single, divorced or widowed

Co-applicant Indicate if Married, Separated or Unmarried*

Unmarried if single, divorced or widowed

Applicant Current address*

Co-applicant Current address

Applicant indicate if you own or rent and how long at current address*

Co-applicant indicate if you own or rent and how long at current address

Applicant - if living at current address less than 2 years provide last address

Co-applicant - if living at current address less than 2 years provide last address

Applicant - indicate if you owned or rented at last address and how long did you live there

Co-applicant indicate if you owned or rented at last address and how long did you live there

Dependents and others who will live with you

Name, Age and Sex identity

Mailing Address: 103 Adams Avenue, Endicott, NY 13760