Date Received:
							(for office use only)
Rebuilding Together Worcester Non-profit Agency Application

Agency Information
Agency:
Agency Director/Title:
Address:					TelNo:
City:				St:		Zip:

Property Information
Do you own the facility?* Yes No

Facility Address:

City:

St:

Zip:

Number of Bedrooms (if residential):

Number of Bathrooms:

Do you have property insurance? Yes No    (This is required for participation in Rebuilding Together Worcester)
Insurance Company:
Insurance Policy number:
* If facility is rented or leased, permission must be granted by owner for improvements and submitted in writing to RTW.

Agency Program Description (type of service offered):

Client Information (please indicate the characteristics of your client population, to include age, race/ethnicities, disabilities, household type, income levels, et cetera).

Repair Wish List (What are the four most important repairs you need at your facility?)
1.		3.
2.		4.

I/we certify that the above information is true and correct to the best of my/our knowledge. I/we realize that failure to provide all information requested could result in our application being invalid. I/we authorize you to check any references necessary to complete the processing of this application for the purpose of receiving housing rehabilitation through Rebuilding Together - Worcester. I/we also understand that any information received will be kept confidential and will be used strictly for determining my/our eligibility for this program.

Signature of Agency Director		Date
Referred by:		Phone:
Return to: Rebuilding Together Worcester P.O. Box 2774 Worcester, MA 01613