Home provider application
     
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  Home Provider Application Form

Please fill in the form and then click the "Submit" button at the bottom of the page to send your application to DMCC.  Please note that first name, last name, and email are required.

 
   

Required Information: first name, last name, email, rent

First name:
Last name:


Your email address:

What is the monthly rent you want to receive? 

 

About the living space you provide:

What rental arrangements will you accept?
housemate pays rent for shared housing 
housemate exchanges services for part of rent 
housemate exchanges services for full rent

If housemate exchanges services —
What types of services will you exchange for rent?
housekeeping
cooking
babysitting
yardwork
companionship
transportation    have auto?
Any other services you will accept?

What type of housing are you sharing?
house
apartment
condo
townhouse
mobile home

Do you rent or own this housing?
rent
own

What facilities do you offer?
private bathroom
private phone
furnished rooms
laundry room access
garage or parking space
bus nearby
grocery nearby
no-stairs
wheelchair access
Any other facilities provided?

About the housemate you will accept:

   

Prefer a female, male or couple?
female   male   couple   no preference

Do you have an age preference?
under 40   40 - 60   over 60   no preference

Would you consider living with children?
no
yes   only young children   only teenagers

Do you object to smoking or drinking?
no smoking   no drinking

Would you consider living with pets?
no
yes   no cats   no dogs

About you:

   

Why do you want to share your home with someone?

Do you have a pet?
no
yes   Type of pet

Do you smoke or drink?
smoke inside   smoke outside
drink socially   drink at home

List all people who live with you (give name, relationship, age):

Describe any physical or medical condition you have that consitutes a special need for match-up arrangement:

Age: Date of birth:
Male Female

Address:

City: State: Zip:

Day phone:

Night phone:

If you want to start over with a clean form, click "Reset."

If your entries are complete, click "Submit" to send your application to DMCC.

Reminder:  This form will not be sent unless you have filled in the required information
at the top of the page (first name, last name, email, rent).

     

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