FY 2013
Quarter ____
Application #_____
Cost of form: GY$ 300
Habitat for Humanity Guyana Inc.
Homepartner Application Form
“What will you build?”
“Strengthening families, empowering communities”
Habitat for Humanity Guyana Inc.values the importance of home ownership and adequate
housing for all Guyanese. We are committed to ensuring that everyone, especially low income
earners, has a decent home to live in. Families are chosen to participate in this program on the
basis of need, without discrimination or favoritism based on race, geography, religion, political
affiliation, friendships, or any other influence. If you are interested in partnering with Habitat for
Humanity Guyana Inc. to build your home or improve your current living conditions please
complete the form below and submit within five (5) days of the stamped date. Supporting
documents you will need are: (1) copy of your transport or land title; (2) two (2) passport size
photographs, and (3) proof of address.
Remember to tell a friend about Habitat!
A – To review before completing application form
1. Are you aware that the mortgage application may or may not be referred to a local financial
institution by Habitat for Humanity Guyana? Yes 
No 
If no, please stop completing this application form and speak with an authorized representative
of Habitat for Humanity Guyana Inc. prior to completing.
2. Are you aware that your mortgage application has to be reviewed by a local financial
institution who will decide if you qualify for a mortgage? Yes  No 
If no, please stop completing this application form and speak with an authorized representative
of Habitat for Humanity Guyana Inc. prior to completing.
Please select the type of service you require (more than one may apply):
 New house
 Core House
 Extension
 Repair/Rehabilitation
 Estimate
 House plan
 Site management  Final inspection
B - Background data:
Name: ____________________________
Other name(s): _______________________
Address: ______________________________________________________________________
Are you married?  Yes
 No
If married, spouse’s name: _____________________
Have you ever owned a house before?  Yes
 No
If yes, provide details: ___________________________________________________________
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FY 2013
Quarter ____
Application #_____
Cost of form: GY$ 300
“What will you build?”
C - Contact information
Telephone number: ___________________
Work number: ____________________
Mobile number: _____________________
Email address:_______________________________
How long have you lived in your present house, apartment or shelter? __________
Please provide the address and directions to your current house, apartment or shelter:
_____________________________________________________________________________
D - Family composition and current housing arrangement
1. Do you have children?
 Yes
 No
If yes, names and ages of children:
(1) Name _________________ Age:_____
(2) Name __________________ Age:_____
(3) Name _________________ Age:_____
(4) Name __________________ Age:_____
2. How many persons currently live with you in your home? __________
3. Are there any other persons besides your children living with you in your home?
 Yes
 No
If yes, please provide names and ages of these persons below:
(1) Name_________________ Age:_____
(2) Name __________________ Age:_____
(3) Name_________________ Age:_____
(4) Name __________________ Age:_____
4. Are you the legal owner of the land you intend to build on?  Yes
 No
5. If you are applying for a repair or rehabilitation, are you the legal owner of the property the
application is made toward?  Yes
 No
6. If you are applying for a new house, how many persons will live with you in the house? _____
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FY 2013
Quarter ____
Application #_____
Cost of form: GY$ 300
“What will you build?”
E - Employment and income status
1. Are you currently employed?  Yes
 No
If yes, state occupation: ________________________________________________________
Name and address of employer: __________________________________________________
Name of your supervisor:_______________________________________________________
2. Are you currently self-employed?  Yes  No
If yes, what is your business? ___________________________________________________
3. Total monthly household income: GY$___________________
4. Total monthly expenses: GY$___________________________
5. Do you have a bank account?  Yes
 No
If yes, at which banks or credit unions?
___________________________________________________
6. Do you have a current loan with any bank, credit union or other financial institution?
 Yes
 No If yes, what is your monthly repayment? GY $ ______________________
7. Are you financially indebted to any bank, credit union, other financial institution, Government
of Guyana or an individual?  Yes
 No
If yes, provide details: __________________________________________________________
8. Are you willing to volunteer with Habitat for Humanity Guyana?  Yes
 No
9. Describe in your own words your present living condition and how the support you seek might
improve it:
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FY 2013
Quarter ____
Application #_____
Cost of form: GY$ 300
“What will you build?”
By signing this form, I acknowledge that I would like to partner with Habitat for Humanity
Guyana Inc. for the intervention I have applied for. I agree to provide or procure security
for the construction site and that Habitat for Humanity Guyana Inc. will provide
construction management, procure labour, procure and transport materials, and assist me
to monitor the construction process and complete the final inspection.
Permission to use Likeness
I also acknowledge that once I enter into an agreement with Habitat for Humanity Guyana
Inc. I hereby give the organization the right to use my likeness, or that of my department(s)
(photograph or video) in promotion or publicity or other related communication in support
of Habitat for Humanity Guyana Inc., without notification or compensation to me.
Applicant’s Signature: _________________________
Thank You!
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Date _________________________