Free Roof Rescue Nomination

Please fill this form out in its entirety to submit your application for our Free Roof Rescue program.

You can also click here to print a paper copy to mail in your nomination.

Nominee information
Nominee first name*
Nominee last name*
Nominee street address*
City*
State*
Zip*
Nominee Phone Number*
Nominee e-mail address
Nominee's number of dependents
Nominee's annual income (approximate)
Is the nominee employed?
- Yes
- No
If yes, name of employer
Please tell us why this nominee should be considered for a free roof.*
We will consider all information provided when making our decision and will especially take into account family situation, financial situation, serious hardships, and physical disability.
Your information
I'm nominating...*
- Myself
- Someone else
If you are nominating yourself, please skip this section. If you are nominating someone you know, please provide your contact information below.
Your first name
Your last name
Your relationship to nominee
Phone number
E-mail address
References (Optional)
Please provide us with contact information for up to three references we may contact to assist in our decision.
References will only be contacted if nominee is a finalist for a free roof.
Reference 1 name
Relationship to nominee
Reference 1 phone number
Reference 1 e-mail address
Reference 2 name
Relationship to nominee
Reference 2 phone number
Reference 2 e-mail address
Reference 3 name
Relationship to nominee
Reference 3 phone number
Reference 3 e-mail address

Nominee information