Giveback 2026 Program Application

1
Your Full Name* This field is required.(Person Filling Out the Form)
First Name
Last Name
2
Your Phone Number* This field is required.
Please enter a valid phone number.
3
Your Email Address* This field is required.
example@example.com
4
Are you nominating yourself or someone else?* This field is required.
Please Select
Please Select
Myself
Someone else
5
Nominee Full Name* This field is required.(Homeowner Needing a Roof)
First Name
Last Name
6
Address of the Home* This field is required.
7
City, State, ZIP* This field is required.
8
Nominee Phone Number* This field is required.
Please enter a valid phone number.
9
Nominee Email Address
example@example.com
10
Why does this person/home need a new roof?* This field is required.Please describe the current condition of the roof and why this nomination is important. Include any hardships, community involvement, or other relevant details.
11
Is the nominee the legal homeowner of the property listed?* This field is required.
Please Select
Please Select
Yes
No
Unknown
12
Are they currently living in the home?* This field is required.
Please Select
Please Select
Yes
No
13
Photos of the current roof (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload a File
Cancelof
14
Other Notes or Comments
15
I agree to the Terms & Acknowledgement* This field is required.By submitting this nomination, I confirm that the information provided is accurate to the best of my knowledge. I understand that the selected recipient must be the legal homeowner and willing to consent to the roof replacement project, including any necessary inspections and publicity.
I agree to the Terms & Acknowledgement
16
Signature* This field is required.
17
Date* This field is required.
Date
Month
Day
Year
Should be Empty: