Emergency Repairs Program - Rose Rock Habitat for Humanity

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Emergency Repairs Program

Applicant Information

Name *

Name

First

First

Last

Last

Address *

Address

Address

Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Phone *

Email *

Monthly Income *

*

By checking this box I certify that I rent, and do not own my home.

Landlord Name and Phone # *

What repairs are needed? *

1. Race (select one or more) *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

I prefer not to provide this information

2. Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

I prefer not to provide this information

*

I understand that the Oklahoma Community Cares partnership grant is specifically for renters. CCHFH will process all applications and notify you if there are any questions.

*

I understand that CCHFH must receive my Landlord's Work Authorization signed form before any work will be completed.

Once your application is received, one of our staff members will contact you to schedule a meeting and complete any additional application information needed.

If you are human, leave this field blank.

Rose Rock Habitat for Humanity is an Equal Opportunity housing agency and Equal Opportunity Affirmative Action employer.

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