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 home?
(For informational purposes. Answer will not affect selection process.)

* Do you own the land?
(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.)

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

* Are you able to help purchase some of the materials?
Yes No Are you able to help purchase some of the materials?

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 Do you have electrical service?

Who is the electrical service provider?

Water source:

Explain:

Wastewater disposal:

Explain:

Heat source:

* Has Experience Mission ever worked on your home?
Yes No

Has Experience Mission ever worked on your home?

* 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 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.)

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

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Address

City

State

Zip

Country

Phone

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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.