Please fill in all fields marked with a *
	Last Name	*
	First Name	*
	Cell Telephone Number
	Daytime Telephone Number	*
	Evening Telephone Number
	Mailing Address	*
	Email Address
	Household Income	*
	Household Size	Choose One12345678*
	Have you lived in Leon County for 1 year or longer	Choose OneYesNo*
	Have you had the same job or verifiable income for 6 months or longer	Choose OneYesNo*
	Are your current living conditions substandard such as overcrowding or poor condition or high crime area	Choose OneYesNo*
	Are you willing to make a small down payment of 500 dollars	Choose OneYesNo*
	Are you willing to live on a lot provided by Habitat	Choose OneYesNo*
	Do you understand and agree that the house size is based on the household size	Choose OneYesNo*
	Additional Comments