Experience Mission(tm)

Home Repair Application Form

Printable General Home Repair Application

All fields with an * are required.

Head of Household Contact

First Name:

Last Name:

Email:

Phone:

Type:

Alt Phone:

Type:

Best Contact Method:

Best time to call:

Property Location

EM Community:

Address:

City:

State/Province:

Zip:

Country:

My mailing address is different than the physical address My mailing address is different than the physical address

Mailing Address (if different)

Address:

City:

State/Province:

Zip:

County/Province:

Country:

Detailed Directions to Home From County Seat:

Home Information

Do you own the home?
(For informational purposes. Answer will not affect selection process.)

Yes No

Do you own the land?
(For informational purposes. Answer will not affect selection process.)

Yes No

If home or land is rented, please provide name, phone, and address of owner:

Are there people in the home who would be able to help work?

Yes No

Are you able to help purchase some of the materials?

Yes No

Note: Experience Mission is not always able to cover all materials costs. If you are not able to help with the purchase of materials this could affect your house being selected.

Number of people living in the household with disabilities:

Monthly household income:

Type of home:

Explain:

Do you have electrical service?

Yes No

Who is the electrical service provider?

Water source:

Explain:

Wastewater disposal:

Explain:

Heat source:

Has Experience Mission ever worked on your home?

Yes No

Are you willing to let EM share your application with other home repair agencies?(EM will only do this if another organization may be able to help.)

Yes No

Are you currently working with any other federal organizations or non-profits in an effort to rebuild your home?

Yes No

Have you applied for any FEMA or disaster relief grant money?

Yes No

Repairs Requested

Please prioritize the needed repairs on the home and describe the top four repairs you would like to submit in this application.

Priority 1:

Brief Explanation of Priority 1:

Priority 2:

Brief Explanation of Priority 2:

Priority 3:

Brief Explanation of Priority 3:

Priority 4:

Brief Explanation of Priority 4:

Additional Comments?

(888)-475-6414

Sign In

You must have a group size of at least 6 members to join this trip. Please view the Small Team trips or call our Servicing Department for more options at 888-475-6414.

View Small Team Trips

For most trips, you must have a group size of at least 6 members. Please view the Small Teams tab on each Community page or call our Servicing Department for more options at 888-475-6414.

Home Repair Application Form

Head of Household Contact

Property Location

Mailing Address (if different)

Home Information

Repairs Requested

Sign In

Which trip are you interested in?

Groups:

Individuals (Age 18-30):

Verify Your Email Address

Which position are you
applying for?

Home Repair Application Form

Head of Household Contact

Property Location

Mailing Address (if different)

Home Information

Repairs Requested

Sign In

Which trip are you interested in?

Groups:

Individuals (Age 18-30):

Verify Your Email Address

Which position are youapplying for?

Which position are you
applying for?