HomeShare Provider Application

HomeShare Provider Application

This application is intended for individuals who are interested in sharing their home.
Today's Date *

Month Day Year
Date Date Picker Icon
How did you hear about HomeShare? *
Personal Information
Full Name *

First Name Last Name
Maiden or other names used: *
You cannot leave blank use NONE if this does not apply.

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Have you lived in another state in the last 3 years? *

Yes No
Please list the state(s) and how long you lived there:
Phone Number *

Area Code Phone Number
Alternate Phone Number

Area Code Phone Number
Email *
example@example.com
Emergency Contact *

First Name Last Name
Relationship to Emergency Contact *
Emergency Contact Phone Number *

Area Code Phone Number
Demographics
Gender *
Age *
Date of Birth *

Month Day Year
Date Date Picker Icon
Marital Status *

Married Single Divorced Widowed Separated
Are You a Veteran? *

Yes No
Ethnicity *

Hispanic/Latinx Non-Hispanic/Latinx
Ethnicity (select all that apply) *

Caucasian/White African American/Black Asian American Indian/Alaska Native Native Hawaiian or Other Pacific Islander
Do you have a disability? *

Yes No
Please explain your disability, what, if any, services you are receiving for your disability and how long have you been living with your disability?
Housing Situation
Current Housing Situation *

Rent Own

Current Housing Address (if different from personl information above)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Type of Home: *
What is your landlord's name and phone number:
If you are renting you will be required to provide a sublet authorization form from your landlord/property owner in order to finalize your match.
How long at current address? *
Number of people in the household (including yourself): *
Financial Information
Are you currently employed? *

Yes No
What is your occupation?
Who is your employer?
What is your income level? *

$10,000/yr or less $10,000 - $14,999 $15,000 - $24,999 $25,000 - $34,999 $35,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 - $149.999 $150,000 - $199,999 $200,000 or more
Do you receive income from any other sources (not employment)? *

Yes No
Source of Income
Amount Received?
Source of Income
Amount Received?
Source of Income
Amount Received?
Source of Income
Amount Received?
HomeShare Match Information

The following information is collected to help us facilitate a good-fit match. Some of the information requested is personal in nature, but your information will be confidential and not disclosed with anyone outside of our HomeShare staff without your written consent.
Have you ever been involved with CPS? *

Yes No
Do you had any criminal convictions? *

Yes No
Do you had any pending criminal charges? *

Yes No
Do you have any motor vehicle violations *

Yes No
If yes, please explain and include dates:
As part of the application process we do a background, reference and tenant record screening. Information you provide will not necessarily preclude you from the program, however it is important that you are honest and disclose this information so we can make a good-fit match. More information will be obtained before the interview to complete the full check.
Do you smoke? *

Yes No
Do you have a pet(s)? *

Yes No
Please list information about your pet(s) below (include type, breed, age, gender, etc.)
Do you drink? *

Yes No
Please share how often you have a drink:
Do you use recreational drugs? *

Yes No
Please share what type of drug(s) and how often you use:
Do you have a health condition(s) that a roommate should know about? *

Yes No
Please explain your health condition(s):
Do you drive? *

Yes No
Do you own a car? *

Yes No
Do you use public transportation? *

Yes No
Is the home located near a grocery store? *

Yes No
Is the home located near a bus line? *

Yes No I don't know
Is the home wheelchair accessible? *

Yes No
Please describe the neighborhood and block where the home is located? *
Please describe the home and the space you will be providing to the roommate, i.e., how many rooms, furnished, size, closet space, shared kitchen, shared bath, laundry, etc.? *
How long do you want this home sharing arrangement to last? *
What concerns or questions do you have about home sharing? *
Please check at least three goals that you want to achieve to become more self-sufficient or gain a better quality of life through home sharing: *

To improve quality of living situation Maintain stable housing Able to meet monthly housing cost To obtain independent housing and not rely on relatives/friends To help someone To increase income Companionship Receive services
Explain Other:
Is this need urgent? *

Yes No
Match Needed By:

Month Day Year
Date Date Picker Icon
Choose one of the following options for your HomeShare match arrangement: *

I am interested in obtaining rent ONLY I am interested in exchanging services for rent ONLY I am interested in some combination of rent and an exchange of service for rent
If you are interested in exchanging services for rent, what type of services are you interested in/or in need of?

Housework/Cleaning Cooking Errands Handyman Transportation Laundry Caregiving Yardwork
Explain Other:
What kind of person would be most compatible with? *
What irritates you about people? *
Do you have some traits that might irritate a roommate? *
What would someone like about you? *
What else would you like to share about yourself? *
Thank you for your interest in the Community Resource Center's HomeShare program. This application is your submission of interest in the HomeShare program and does not guarantee you approval into the program.

At this time the Community Resource Center is only taking applications for Providers (those who have a home to share) and using these applications to create an interest list. You will be contacted by a HomeShare staff person to discuss the next steps (background check, in-person interview, reference check, home visit, etc.) within 6-8 weeks or longer depending on staff's availability.

This is a new program of the Community Resource Center and it is still being developed. The goal is to be fully operational and ready to begin making matches in the fall of 2019. In the meantime if you have any questions or concerns please email us at info@crc-sc.org or call (360) 629-5257.
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HomeShare Provider Application

Personal Information

Demographics

Housing Situation

Financial Information

HomeShare Match Information