Home Repair Request For Service Form: This interest form is the first step of the process, and is not the full application. You will be contacted after submitting this to complete a full application.

This program only serves homeowners in the California Bay Area. Please do not fill out this form if you are located outside of this area.

Section 1. Homeowner Information

Applicant 1

First Name

Middle Name

Last Name

Gender

Race

Ethnicity

Applicant 1 Current Address This program only serves homeowners in the California Bay Area.

Street

City

State

Zip Code

Applicant 1 Contact Info

Preferred Method of Contact

Primary Phone

Format 999-999-9999

Alternate Phone

Format 999-999-9999

Applicant 2

Is there another Applicant?

YesNo

Applicant 2

First Name

Middle Name

Last Name

Gender

Race

Ethnicity

Applicant 2 Current Address This program only serves homeowners in the California Bay Area

Street

City

State

Zip Code

Applicant 2 Contact Info

Preferred Method of Contact

Primary Phone

Format 999-999-9999

Alternate Phone

Format 999-999-9999

Section 2: Contact Information

Who is the Primary Contact

Other - Description

Primary Contact Info

If the Primary Contact is someone other than the Homeowner, please provide their contact info below:

Primary Contact Name

Relationship to Homeowner?

Primary Contact Address

Primary Contact Phone

Format 999-999-9999

Phone Type

Primary Contact Email

Primary Contact Preferred Language?

If English is not your preferred language, is there an English who can help with the application process as needed (e.g. family member, friend, neighbor)?

YesNo

(please list English speaker as the Primary Contact above.)

How did you hear about this Home Repair program?

Please provide more detail on how you heard about this Home Repair Program

Section 3: Homeowner Priorities

What are your top 4 priorities for repair?

Priority 1

Priority 2

Priority 3

Priority 4

When you click submit below it may take a few moments. Please only hit the Submit button once. We’ll double check to make sure you have submitted all the necessary fields. When you've filled out any of the missing pieces, submit again.

Thank you for taking the time to complete our Request for Service Form.

Habitat for Humanity East Bay/Silicon Valley Home Preservation Department