Experience Mission(tm)

Home Repair Application Form

General Information
Printable McDowell County Home Repair Application Printable General Home Repair Application
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:	*required for US or CA only
* Zip:
County:
* Country:

Mail To (if different from above)
Address:
City:
US/CA State:
Zip:
County/Province:
Country:

* Detailed Directions to Home From County Seat:
* 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

Household Information
* Year house was built:
* How many years have you lived in this home?
* Do you own the home? For informational purposes only, will not affect selection process. Yes No
* Do you own the land? For informational purposes only, will not affect selection process. Yes No
If home or land is rented, please provide name, phone, and address of owner:
* People living in the house: Provide full names and birth year of everyone residing in the home. Please also indicate if they are a military veteran.
* 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:

Home Details
* Type of home:	Explain:
* Number of bedrooms:
* Number of bathrooms:
* Do you have electrical service?	Yes No
Who is the electrical service provider?
* Water source:	Explain:
* Wastewater disposal:	Explain:
* Heat source:

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:

Miscellaneous

Other? Additional Comments?

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Last Name

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.

General Information

Household Information

Home Details

Repairs Requested

Miscellaneous

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