Thanks for your interest in Critical Home Repair!

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Lead Status

Company

Record Type ID

Lead Record Type Input

Thank you for your interest in our Critical Home Repair program! To receive an application your information will need to be added onto our Interest Form. Your property will be pre-screened based on basic property requirements for our Critical Home Repair program. Should your property pass the initial screening, you will be notified when applications will become available to you.

Filling out this form does not qualify you for our Critical Home Repair program and does not guarantee that you will be served through our program.

If you have any questions, please call our Critical Home Repair hotline: 704.716.5639

IS THIS A CRITICAL HOME REPAIR INTEREST FORM FOR YOURSELF OR A REFERRAL FOR SOMEONE YOU KNOW?

MYSELFSOMEONE ELSE

Person filling out this form

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Last

Phone

Email

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HomeOwner Name

First

Last

Phone

Email

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Who should we use for the primary contact? HomeownerPerson Filling Out Form

STREET ADDRESS

CITY

Note: Home must be in Charlotte, Pineville, Huntersville, Cornelius, Davidson, Iredell County, Gaston County to qualify for Habitat Charlotte Region’s Critical Home Repair program.

STATE

ZIP CODE

LANGUAGE PREFERENCE

ENGLISHSPANISHFRENCH

ARE YOU A VETERAN OF THE U.S. ARMED FORCES?

YesNo

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