Homeprovider Application Homeprovider Application Form Prospective home providers use this form to apply to become home providers. NameThis field is for validation purposes and should be left unchanged.Name(Required)Please include middle name, it is important for our records. First Middle Last Phone number(Required)Email(Required) Enter Email Confirm Email Street Address(Required)Please note: our program only serves home providers in Baltimore City and Baltimore County. City(Required)State(Required)Zip Code(Required)What county is your home located in?(Required)Please note: Our program only serves Home Providers in Baltimore City and Baltimore County. Baltimore City Baltimore County Gender(Required)What best describes your household? Female Male Nonbinary Date of Birth(Required) MM slash DD slash YYYY Contact person (if other than homeowner)Contact Phone NumberHow did you hear about St. Ambrose Homesharing?(Required)Why do you want to share your home now?(Required) Extra income Companionship To help others All of the above Other Has your decision to look into home sharing been influenced by your mortgage payments, foreclosure, or risk of foreclosure?(Required) Yes No How long have you lived in Baltimore?(Required)How long have you lived in your current home?(Required)Do you own your home?(Required)If renting, please include a letter from your landlord indicating permission to sublet. Yes No What is your marital status?(Required) Single Married Separated Divorced Widowed Who are the other occupants in your house and what are their ages?(Required)Have you ever had a problem with alcohol or drugs?(Required) Yes No If you answered yes, how long have you been clean and sober (minimum one year required)?Have you ever been convicted of a crime?(Required) Yes No If yes, please provide details as well as dates.Please indicate your employment status: Employed Retired Other Employer NameEmployer Street AddressEmployer CityEmployer StateEmployer Zip CodeEmployer Phone NumberYour PositionYour household's yearly or monthly gross (pre-tax) income:(Required)Source(s) of Income:(Required)Examples: Employment, SSI, pensions, public assistance, etc. Please provide us with a copy of your documentation at the time of your interview. Your highest level of education completed:(Required) Primary High school / GED Vocational College Other Do you have a health condition a homesharer should know about? If yes, please describe.Your race (for grant reporting purposes only) – Please mark all that apply:(Required) American Indian / Alaska Native Asian Black / African American Hispanic Native Hawaiian / Other Islander White Other Multi-Racial Category Information for HomesharingI am interested in being a host for a Journey of Hope young adult (young adult aged 18-24 who was experiencing homelessness)(Required) Yes No Describe the space available for a homesharer (1 room, 2 rooms, private bath, apartment, etc).(Required)Is the space furnished (please describe)?(Required)What is the desired rent you'd like to receive per month?(Required)What is the minimum rent you'd accept per month?(Required)Are utilities included?(Required) Yes No Are utilities included?(Required) Yes No Are you investigating other housing possibilities? Selling Moving No Other CONSENT TO OBTAIN INFORMATION FORMPlease list the names of four people who have known you for AT LEAST FIVE YEARS that can serve as a personal reference for you. Include a former roommate or landlord and a combination of the following – one family member, professional person, associate, clergy, or friend. Reference #1: Name(Required)If applicable, choose the most recent person with whom you have lived. Reference #1: Relationship(Required)Reference #1: Phone Number(Required)Reference #2: Name(Required)Reference #2: Relationship(Required)Reference #2: Phone Number(Required)Reference #3: Name(Required)Reference #3: Relationship(Required)Reference #3: Phone Number(Required)Reference #4: Name(Required)Reference #4: Relationship(Required)Reference #4: Phone Number(Required)CAPTCHA
