Waiting List Registration

Waiting List Registration
Name*

First NameLast Name
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Do you have a second mortgage or open line of credit?*

YesNo
How many people, including yourself, live in your home?*
Are there any children 18 or older living with you?*

YesNo
Are you or any member of your household disabled?*

YesNo
Are there any Code Violations on the property?*

YesNo
Property type:*

Single-FamilyVillaTownhouseCondoDuplex
Does it have an attached roof?*

YesNo
Are the property taxes current?*

YesNo
Annual household income (including child support and all children over 18 living in the house):*
Property assessment value (Per BCPA):*
Are you a US Citizen?*

YesNo
Are you married?*

YesNo
Do you own any other real estate?*

YesNo
Do you currently have flood insurance?*

YesNo
Which program are you applying for?:*

Home RepairBarrier FreeRoof
By typing my name in the below space, I am electronically signing this form. By signing this electronic signature certifies the information to be true, accurate, and complete.*

First NameLast Name
Should be Empty: