Form

First Name: *
Last Name: *
E-mail: *
Address *
City *
State *
Zip Code *
Phone: *
Do you or the nominee own the home? *	Yes No
Are you/they listed on the deed? *	Yes No
Annual Household Income *
Please list all members of your houshold. Name, Age, Relationship *
Have any members of household been convicted of a crime? If yes please describe. (We will be doing background checks as part of the selection process) *
Have any members been involved with charity or volunteer work? If yes please describe. *
Please provide us with detailed information about your current situation and the shape of your home and let us know why you should be chosen to receive the Renovation. (Please limit this to 500 words) *
If selected are you willing to have your name, pictures and video used to promote the renovation? *	Yes No
By Signing this form you certified that all information is true at the time of signing this form. You can sign this application and submit it electronically by typing your full name in the box below.
Terms and ConditionsIf selected you will execute all waivers and consent forms as required by Buresh Home Solutions. Buresh Home Solutions will perform the selected home improvement and will not be responsible for any other pre existing conditions in the home. Selected home will also receive additional protection by offering the same warranties that we do for all of our customer’s. Only selected candidate will be contacted once the Selection Board has made its decision. All choice are final and no inquiry will be responded to during the selection process or after the selection. The scheduling of the job in 2009 will be made under the sole discretion of Buresh Home Solutions and its management. The selected homeowner will need to be present and make the premises available at the time the work begins and until completed for all Buresh Home Solutions team members.
Please type your full name *
Today's Date
If you are nominating someone else please provide your contact information as well.