A United Way Member Agency
B u i l d i n g h o m e s, c o m m u n i t i e s a n d h o p e
Stop! Before completing the application, please read through these guidelines
to make sure you understand the process prior to applying.
Welcome to the Habitat for Humanity of St. Augustine/St. Johns County Homeownership Application
Process. There are some things you need to know before completing this application.
1. We are going to verify your income and it must be projected to continue for at least three years.
a. This means we will need pay stubs, bank statements, proof of benefits or child support,
etc.
2. If you are married, you and your spouse must be listed on the application.
3. We are going to review your credit. You must have a credit history free of bankruptcy, evictions,
and foreclosures for the past 7 years.
a. Our homeowners receive a mortgage for their home and must make monthly mortgage
payments on their home.
4. We do not offer emergency housing.
a. This process can take 12-24 months. Applicants must understand this is not a quick fix but
a journey to homeownership.
5. You will be required to complete sweat equity hours as part of your partnership with Habitat for
Humanity. Each individual applicant is required to complete 250 hours. Hours are worked on the
construction site and also include required educational workshops.
a. We work on the construction site on Fridays and Saturdays 8am-3pm. Homeowners are
required to work at least 14 hours each month to show their willingness to partner. The
homeowners must accumulate the minimum number of sweat equity hours (250 for each
individual applicant) before they are able to close on their home.
b. If you are disabled and unable to perform your sweat equity hours you will be allowed to
designate one friend or family member to perform your individual sweat equity hours after
providing proof of being unable to complete sweat equity hours on your own.
6. Habitat for Humanity of St. Augustine/St. Johns County staff does not determine who gets
approved for a home. Habitat staff serve to help the homeowners through the process but the
Homeowner Selection Committee and the Board of Directors approve families for homeownership
based on our four criteria.
7. We build approximately 6 homes per year. When reviewing applications, selections will be
determined by choosing those that best meet the 4 main criteria.
8. Please visit our website at http://www.habitatstjohns.org/faq/ for answers to more frequently asked
questions.
If you have questions or need additional information, please don’t hesitate to contact our Family
Services Manager, Angela Hamilton, for further assistance.
Email: [email protected]
Phone: 904-826-3252 ext 2005
1
A United Way Member Agency
B u i l d i n g h o m e s, c o m m u n i t i e s a n d h o p e
Welcome to the Habitat for Humanity Application Process!
This is a checklist of documentation necessary to begin the Habitat for Humanity homeowner
application process. All documents must be collected by the applicant and submitted with the
application for review.
Please collect all of the below documents and complete the application. Once all documents are
collected and the application is complete, you may submit the application in one of the following
ways:
1.) Submit hard copy application & supporting documents at 7 Hopkins Street, St. Augustine, FL
32084
or
2.) Submit electronic application & supporting documents via email at
[email protected]
APPLICANT & COAPPLICANT INFORMATION
 Photo ID
 Social Security Card(s) of applicant(s) and dependent(s)
 Birth certificate(s) of dependent child(ren)
 Documentation of legal custody (if applicable)
 Documentation of divorce decree (if applicable)
EMPLOYMENT, OTHER INCOME, OR ASSETS
 Last 2 months paycheck stubs
 Verification of child support & Case No. (if applicable)
 Verification of any income (i.e. social security, SSI, Veterans, Disability, food stamps, etc.)
 Last year’s federal income tax return (1040) and W2 or tax return transcript
 2 months of checking and/or savings account statements.
ITEMS TO BE INCLUDED WITH APPLICATION
 $20.00 for credit report
 Verification of denial of a mortgage loan (if you have applied)
If you have any questions, please contact Angela Hamilton, the Family Services Manager, at
(904) 826-3252 x 2005 or [email protected]
2
Application Packet
PHASE 1
Directions:
Read ALL the requirements on this page.
If you meet the criteria, complete this entire application packet.
There are 3 parts to the Application Packet:
1. Check List
2. Release of Information Waiver
3. Application for Housing
Return ALL 3 parts along with ALL CURRENT proof of income for:
the Applicant, Co-Applicant and adult children that will live in the home.
Failure to complete the entire application and/or failure to submit proof of income and/or any other
requested documents will result in a denial of an incomplete application.
Requirements
- Have a need for shelter
- Have the ability to pay a monthly mortgage payment & have steady income for 2 years.
- Live or work in St. Johns County for at least 1 year.
- Show willingness to partner with Habitat
- Be willing to perform a minimum of 250 hours (per individual) of "sweat equity" by helping build Habitat
homes, including your own
- Meet the income guidelines
-Complete a mandatory Home Buyer Education Class.
- Have acceptable credit (No unpaid collections or judgments)
- May not have Foreclosure, bankruptcy or evictions within the past 7 years
- Must be eligible to open/maintain a savings account
- Must be unable to qualify for traditional financing
2016 Income Guidelines
Gross Monthly Income
How Many In
Household?
Monthly
Minimum
Gross Annual Income
Monthly
Maximum
Annual
Minimum
Annual
Maximum
1
$1,138
$4,550
$13,650
$54,600
2
$1,300
$5,200
$15,600
$62,400
3
$1,463
$5,850
$17,550
$70,200
4
$1,623
$6,490
$19,470
$77,880
5
$1,753
$7,010
$21,030
$84,120
6
$1,883
$7,530
$22,590
$90,360
We are pledged to the letter and spirit of the U.S. policy for the achievement of equal housing opportunity throughout the
nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to
obtaining housing because of race, color, religion, sex, handicap, familial status, or national origin.
3
Phases of the Home Buying Program
Phase 1- Apply
 Application Process (See possible dates for these events on page 5)
 Credit Review
(If meet criteria move to Phase 2)
Phase 2 - Verification
 Employment & Rental Verification
 Sex Offender & Criminal Verification
 Home Visit & Good Faith Hours (See possible dates for these events on page 5)
 Family Selection Review
 Board of Directors Review
(If verification is met move to Phase 3)
Phase 3- New Partner Family
 New Partner Family Meeting
 Start Working Sweat Equity
 Home Buyer Education & Additional Workshops
 Home Buyer Education & Budget Class Financial Literacy Workshops
(Once fulfilled move to Phase 4)
Phase 4 - Home Selection
 Lot Selection
 Interior/ Exterior Home Color Selections
 Purchase Agreement
 Re-verifications
 Submit Down Payment
(Once fulfilled move to Phase 5)
Phase 5- Home Purchase/Closing





Homeowners Insurance
Home Dedication
Submit Closing Cost
Closing Purchase
Move In
4
Important Dates to Remember:
Dates for Phases 1 and 2 during the 2017 year are listed below. Please note, dates are
tentative and subject to change. Additionally, in the event you move to phase 2, you
will be notified by the Family Services Manager. If you have questions regarding these
dates, please contact the Family Services Manager for assistance.
January 2017 Open Enrollment
Phase 1
Open Enrollment
Tue 1/3/17
Tue 1/31/17
Sat 2/18/17
Tue 2/28/17
Sat 2/25/17
Tue 3/7/17
Phase 2
Good Faith Hours
Home visit
April 2017 Open Enrollment
Phase 1
Open Enrollment
Tue 4/4/17
Fri 4/28/17
Sat 6/3/17
Tue 6/6/17
Sat 6/10/17
Tue 6/13/17
Phase 2
Good Faith Hours
Home visit
July 2017 Open Enrollment
Phase 1
Open Enrollment
Tue 7/4/17
Fri 7/28/17
Fri 9/8/17
Tue 9/5/17
Sat 9/9/17
Tue 9/12/17
Phase 2
Good Faith Hours
Home visit
October 2017 Open Enrollment
Phase 1
Open Enrollment
Tue 10/3/17
Tue 10/31/17
Sat 12/2/17
Tue 12/5/17
Sat 12/9/17
Tue 12/12/17
Phase 2
Good Faith Hours
Home visit
5
Frequently Asked Questions
Q. How long does it take to get an answer or response after I complete an application?
A. You will get a response by mail within 30 days.
Q. Can I count child support income?
A. Yes, you can.
Q. What does steady employment mean? And am I required to have the same job for 2 years?
A. Steady employment means income coming in for at least two years without any gaps. No, you are not required to have
the same employer for that time, it is ok to have had worked for more than 1 employer.
Q. If I have my own land, will you build on it?
A. If you are accepted into the program and you have land in St. Johns County, (we will not build outside of St. Johns
County) the Construction Manager will look at your land and determine if the land is buildable. If so, it is possible we could
build on your land. Additionally, you cannot have saleable assets (including land) valued at more than $20,000.
Q. If I have a felony, am I automatically disqualified?
A. No, we have a system that determines eligibility for criminal backgrounds. All applicants 18 years of age or older, that
will live in the home, will be required to complete a background check.
Q. If I have a sexual offender offense, am I automatically disqualified?
A. Yes.
Q. Am I required to have perfect credit or a high credit score?
A. We do not determine eligibility by credit score. However, you cannot be approved with unpaid collection judgments,
liens or bankruptcy. Bankruptcies have to be discharged at least 7 full years before you can qualify. All collections,
judgments & liens must be paid or settled before you can be accepted into the program. If you have any of these issues,
you are encouraged to attend credit counseling to determine what needs to take place to repair your credit.
Q. Am I required to attend the Homebuyer classes? What if I completed the class before I was
accepted?
A. Once you are accepted into the Program, yes, you are required to attend a Homebuyer Class. You will receive a
Certificate once you’ve completed the course.
Q. Can I choose where I want to live?
A. Yes, from our list of available lots.
Q. What if I do not want to live on the lots that you offer me?
A. You will have the opportunity to choose from our available lots. If you do not select a lot from the options presented,
you could be de-selected from the program.
Q. Do I have to be a US Citizen?
A. You must be a citizen of the United States or have been granted permanent residency status. We will require
documentation for either status.
Q. Does Habitat rent homes?
A. No. We only build and sell homes.
6
Check List
Applicant Name__________________________________ Date__________
Co-Applicant Name_________________________________
1. Do you meet the income guidelines for your family size listed on page 1?
Yes
No
2. Are you willing to partner with us & willing to perform 250 hours (per individual) of sweat equity?
Yes
No
3. Do you have a need for shelter?
Yes
No
5. Have lived or worked in St. Johns County for at least 1 year?
Yes
No
6. Have you had a steady income for 2 years with NO gaps in my employment at all?
Yes
No
8. Do you have acceptable credit with NO unpaid collections or judgments?
Yes
No
9. Have you ever declared bankruptcy?
Yes
No
4. Is your current need for shelter/living situation: (circle all that apply)
Overcrowded
Substandard Housing/ Poorly Maintained
Cost Burdened (due to housing expenses)
Unable to qualify for a Conventional Mortgage due to income level
Current Section 8 or MHA resident
Homelessness
a. If no, how long of a gap? ____________
7. How many hours do you work per week on your current job? ____________
a. If yes, has been discharged for at least 7 years?
10. If approved how many people will live in the home? # of Adults?_____# of Children (under 18)? ______
13. Do you own a home or land?
14. Are you currently in the Military?
Yes
Yes
No
No
15. Are you a Veteran?
Yes
No
16. Are you willing to live in the areas in which we are building?
Yes
No
17. Is there an area you do you NOT want to live in?
Yes
No
If yes, please explain:
______________________________________________________________________________
______________________________________________________________________________
7
Check List continued
18. Email Address ___________________________________________________________________
19. Cell Phone Number________________________________________________________________
20. Home Phone Number ______________________________________________________________
21. What is the best way to communicate with you between 8am-6pm? (circle all that apply)
Email
Text
Home
Work
Mail
22. How did you hear about Habitat? (circle all that apply)
Church Presentation/Meeting
Homeowner (Name _________________) Workplace
Agency
Festival/ Health Fair
Walk In/Office Website
23. Have you previously applied for Habitat for Humanity?
Yes
No
a. If yes, when?
_____________________________________
24. I understand that if any of my contact information changes, I am responsible for notifying Habitat of any
changes.
Yes
No
25. I consent to allow Habitat to pull my credit report to verify my credit score, which requires a $20
payment that is due when the application is submitted.
Yes
No
26. I consent to allow Habitat to provide a copy of my credit report to the Mortgage and Credit Center for
free counseling services as required by the Habitat Program.
Yes
No
27. I understand that I am not in the Habitat program until I am approved by the Board of Directors.
Yes
No
_____________________________________
Applicant’s Signature
_____________________________________
Co-Applicant’s Signature
_____________________________________
Date
_____________________________________
Date
8
Release of Information Waiver
To Whom It May Concern:
I/We hereby authorize the release of any personal and financial information requested
Habitat for Humanity of St. Augustine/St. Johns County, including:
Employment Verification
Personal Credit References
Income Verification
Current & Previous Rental History
Social Services Payment Certification
Bank Statements
Credit Reports
Sexual Offender Check
Criminal Background Check
Tax Returns
A photocopy of this authorization may be deemed to be the equivalent of the original and may be
used as a duplicate original.
_____________________________________
Applicant Name (Printed)
_____________________________________
Co-Applicant Name (Printed)
_____________________________________
Date of Birth
_____________________________________
Co-Applicant Date of Birth
_____________________________________
Social Security Number
_____________________________________
Co-Applicant Social Security Number
_____________________________________
Applicant’s Signature
_____________________________________
Co-Applicant’s Signature
_____________________________________
Date
_____________________________________
Date
We are pledged to the letter and spirit of the U.S. policy for the achievement of equal housing opportunity throughout the
nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to
obtaining housing because of race, color, religion, sex, handicap, familial status, or national origin.
9
Habitat for Humanity of St. Augustine/St. Johns County
7 Hopkins Street
St. Augustine, FL 32084
904-826-3252
Application
We are pledged to the letter and spirit of U.S. policy for the
achievement of equal housing opportunity throughout the nation.
We encourage and support an affirmative advertising and marketing
program in which there are no barriers to obtaining housing because
of race, color, religion, sex, handicap, familial status, or national origin.
Habitat Homeownership Program
Dear Applicant: Please complete this application to determine if you qualify for the Habitat for Humanity homeownership program. Please fill out the application
as completely and accurately as possible. All information you include on this application will be kept confidential in accordance with the Gramm-Leach-Bliley Act.
1 . A P P L I C A N T I N F O R M AT I O N
Ap p l i c a n t
Co-applicant
Applicant’s name
Social Security number
Co-applicant’s name
Home phone
Age
Social Security number
Home phone
Age
□Married □Separated □Unmarried (Incl. single, divorced, widowed) □Married □Separated □Unmarried (Incl. single, divorced, widowed)
Dependents and others who will live with you (not listed by co-applicant)
Dependents and others who will live with you (not listed by co-applicant)
Name
Name
AgeMaleFemale
AgeMaleFemale
____________________________________ _____ □
□
____________________________________ _____ □
□
____________________________________ _____ □
□
____________________________________ _____ □
□
____________________________________ _____ □
□
____________________________________ _____ □
□
____________________________________ _____ □
□
____________________________________ _____ □
□
____________________________________ _____ □
□
____________________________________ _____ □
□
□Own □Rent
Present address (street, city, state, ZIP code)
Number of years____________________________
□Own □Rent
Present address (street, city, state, ZIP code)
Number of years____________________________
I f l i v i n g a t p r e s e n t a d d r e s s f o r l e ss t h a n t w o ye a r s, c o m p l e t e t h e f o l l o w i n g
Last address (street, city, state, ZIP code)
□Own □Rent
Number of years____________________________
Last address (street, city, state, ZIP code)
□Own □Rent
Number of years____________________________
2 . F O R O F F I C E U S E O N LY – D O N O T W R I T E I N T H I S S P A C E
Date received: ______________________________________________ Date of selection committee approval:____________________________
Date of notice of incomplete application letter: _____________________ Date of board approval: ________________________________________
Date of adverse action letter: ___________________________________ Date of partnership agreement:__________________________________
10
3 . W I L L I N G N E S S T O PA R T N E R
To be considered for Habitat homeownership, you and your family must be willing to complete a certain number of “sweat-equity” hours. Your help in
building your home and the homes of others is called “sweat equity” and may include clearing the lot, painting, helping with construction, working in
the Habitat office, attending homeownership classes or other approved activities.
YesNo
Applicant
I AM WILLING TO COMPLETE THE REQUIRED SWEAT-EQUITY HOURS:
Co-applicant
□ □
□ □
4. PRESENT HOUSING CONDITIONS
Number of bedrooms (please circle)
12345
Other rooms in the place where you are currently living:
□ Kitchen □ Bathroom
□ Living room □ Dining room
□ Other (please describe)____________________________________
_______________________________________________________________________________________________________________________
If you rent your residence, what is your monthly rent payment? $
/ month
(Please supply a copy of your lease or a copy of a money order receipt or canceled rent check.)
Name, address and phone number of current landlord:____________________________________________________________________________
_______________________________________________________________________________________________________________________
In the space below, describe the condition of the house or apartment where you live. Why do you need a Habitat home?
5 . P R O P E R T Y I N F O R M AT I O N
If you own your residence, what is your monthly mortgage payment? $_______________ / month Unpaid balance $__________________________ Do you own land?
□ No □Yes
Monthly payment $_______________________ Unpaid balance $_________________________
If you wish your property to be considered for building your Habitat home, please attach land documentation.
6 . E M P L O Y M E N T I N F O R M AT I O N
Ap p l i c a n t
Name and address of CURRENT employer
Co-applicant
Years on this job
Name and address of CURRENT employer
Monthly (gross) wages
$
Type of business
Business phone
Years on this job
Monthly (gross) wages
$
Type of business
Business phone
I f w o r k i n g a t c u r r e n t j o b l e s s t h a n o n e ye a r, c o m p l e t e t h e f o l l o w i n g i n f o r m a t i o n
Name and address of LAST employer
Years on this job
Name and address of LAST employer
Monthly (gross) wages
$
Type of business
Business phone
Years on this job
Monthly (gross) wages
$
Type of business
Business phone
11
7 . M O N T H LY I N C O M E
Alimony, child support or separate maintenance income need not be revealed if the applicant or co-applicant does not chose to have it considered
for repaying this loan.
Income S ource
Ap p l i c a n t
Co-applicant
O t h e r s i n h o u se h o l d
Total
Wages
$
$
$
$
TANF
$
$
$
$
Alimony
$
$
$
$
Child support
$
$
$
$
Social Security
$
$
$
$
SSI
$
$
$
$
Disability
$
$
$
$
Section 8 housing
$
$
$
$
Other _________________
$
$
$
$
Other _________________
$
$
$
$
Other _________________
$
$
$
$
Total
$
$
$
$
H o u se h o l d m e m b e r s w h o se i n c o m e i s l i st e d a b o ve
PLEASE NOTE:
Self-employed applicants
may be required to provide
additional documentation
such as tax returns and
financial statements.
Na me
I n c o m e so u r c e
Monthly income
D ate of bir th
8 . S O U R C E O F D O W N P AY M E N T A N D C L O S I N G C O S T S
Where will you get the money to make the down payment (for example, savings or parents)? If you borrow the money, whom will you borrow it from,
and how will you pay it back?
9. ASSETS
N ame of bank, saving s a n d
loan, credit union, e t c .
Ad d r e s s
C i t y, st a t e
ZIP
C ur r ent
balance
Account number
$
$
$
$
$
$
$
$
$
12
10. DEBT
To w h o m d o yo u a n d t h e c o - a p p l i c a n t ( s) o w e m o n e y?
Ap p l i c a n t
Monthly
p a y me n t
Account
Co-applicant
Unpaid
balance
Months
left to pay
Monthly
p a ym e n t
Unpaid
balance
M onths
left to pay
Other motor vehicle
$
$
$
$
$
$
Boat
$
$
$
$
$
$
$
$
$
$
$
$
Alimony
$
$
$
$
$
$
Child support
$
$
$
$
$
$
Credit card
$
$
$
$
$
$
Credit card
$
$
$
$
$
$
Credit card
$
$
$
$
$
$
Total medical
$
$
$
$
$
$
Other
$
$
$
$
$
$
Other
$
$
$
$
$
$
$
$
$
$
$
$
Furniture, appliance, televisions
(includes rent-to-own)
Total
M o n t h l y e x p e n se s
Account
Ap p l i c a n t
Co-applicant
To t al
Rent
$
$
$
Utilities
$
$
$
Insurance
$
$
$
Child care
$
$
$
Internet service
$
$
$
Cell phone
$
$
$
Land line
$
$
$
Business expenses
$
$
$
Union dues
$
$
$
Other
$
$
$
Other
$
$
$
Other
$
$
$
$
$
$
Total
13
1 1 . D E C L A R AT I O N S
P l e a s e c i rcl e the w or d th a t b e s t a n s w er s t he f o l l ow i n g qu e s t i on s f o r y o u a n d t he c o - a p pl i c a nt
Applicant
a.
Do you have any outstanding judgments because of a court decision against you?
b.
Have you been declared bankrupt within the past seven years?
c.
Have you had property foreclosed on in the past seven years?
d.
Are you currently involved in a lawsuit?
e.
Are you paying alimony or child support?
f.
Are you a U.S. citizen or permanent resident?
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ No
□ No
□ No
□ No
□ No
□ No
Co-applicant
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ No
□ No
□ No
□ No
□ No
□ No
If you answered “yes” to any question a through e, or "no" to question f, please explain on a separate piece of paper.
1 2. AU T H O RI Z ATI ON AN D R EL EA SE
I understand that by filing this application, I am authorizing Habitat for Humanity to evaluate my actual need for the Habitat homeownership
program, my ability to repay the no-interest loan and other expenses of homeownership, and my willingness to be a partner through sweat equity. I
understand that the evaluation will include personal visits, a credit check and employment verification. I have answered all the questions on this
application truthfully. I understand that if I have not answered the questions truthfully, my application may be denied, and that even if I have already
been selected to receive a Habitat home, I may be disqualified from the program. The original or a copy of this application will be retained by
Habitat for Humanity even if the application is not approved.
I also understand that Habitat for Humanity screens all applicant families on the sex offender registry. By completing this application, I
am submitting myself to such an inquiry. I further understand that by completing this application, I am submitting myself to a criminal
background check.
I/we, the applicant(s) certify that I/we have answered all of the questions on this application truthfully. I/we understand if I/we have not
answered the questions truthfully or not report changes in circumstances during the qualifying process, I/we may be denied, a nd even
if I/we have already been selected to receive a Habitat home, I/we may be disqualified from the program. I/we also understand that
Habitat for Humanity of St. Augustine/St. Johns County has a Zero Tolerance Policy and if any illegal activity is conducted on or
around the premises of a Habitat home, the conduct could result in foreclosure.
Applicant signature
X
Date
Co-applicant signature
Date
X
PLEASE NOTE: If more space is needed to complete any part of this application, please use a separate sheet of paper and attach it to this
application. Please mark your additional comments with “A” for applicant or “C” for co-applicant.
14
Applicant's name_______________________________________ Co-applicant's name_______________________________________________
1 3 . I N F O R M AT I O N F O R G O V E R N M E N T M O N I T O R I N G P U R P O S E S
PLEASE READ THIS STATEMENT BEFORE COMPLETING THE BOX BELOW: The following information is requested by the federal government for
loans related to the purchase of homes, in order to monitor the lender’s compliance with equal credit opportunity and fair housing laws. You are
not required to furnish this information, but are encouraged to do so. The law provides that a lender may neither discriminate on the basis of this
information, nor on whether you choose to furnish it or not. However, if you choose not to furnish it, under federal regulations this lender is
required to note ethnicity, race and sex on the basis of visual observation or surname. If you do not wish to furnish the information below,
please check the box below.
Ap p l i c a n t
Co-applicant
□ I do not wish to furnish this information
□ I do not wish to furnish this information
Race (applicant may select more than one racial designation):
Race (applicant may select more than one racial designation):
Ethnicity:
Ethnicity:
□ American Indian or Alaska Native
□ Native Hawaiian or other Pacific Islander
□ Black/African-American
□ White
□ Asian
□ Hispanic or Latino
Sex:
□ Female
□ Non-Hispanic or Latino
□ American Indian or Alaska Native
□ Native Hawaiian or other Pacific Islander
□ Black/African-American
□ White
□ Asian
□ Hispanic or Latino
Sex:
□ Male
□ Female
□ Non-Hispanic or Latino
□ Male
Birthdate: ______ / ______ / ______
Birthdate: ______ / ______ / ______
Marital status:
Marital status:
□ Married
□ Separated
□ Unmarried (Incl. single, divorced, widowed)
□ Married
□ Separated
□ Unmarried (Incl. single, divorced, widowed)
To b e c o mp l e t e d on l y b y t h e p e r so n c o n d u c t i n g t h e i n t e r vi e w
Interviewer’s name (print or type)
This application was taken by:
□ Face-to-face interview
Interviewer’s signature
Date
□ By mail
□ By telephone
Interviewer’s phone number
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