Preliminary Guest Application

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Email *

Name *

Age *

Home Address *

City *

State *

Zip Code *

Phone number (Please use dash (-) to separate numbers e.g. 555-555-5555) *

Preferred Method of Contact *

Telephone

U.S. Mail

Reason(s) for your interest in becoming a home sharing guest: (Please check appropriate box/boxes). *

Financial

Companionship

Other:

Required

Amount you are able to contribute toward your potential host's monthly household expenses *

(in dollars)

Are you interested in providing service(s) for a home sharing host in exchange for no or a small contribution toward household expenses? *

Yes

Maybe

How did you hear about the Home Sharing Program? *

Subway Ad

Bus Ad

Con Edison

Social Media

311

DFTA- New York City, Department of The Aging

Other:

Required

Send me a copy of my responses.

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