Apply Now

Complete the form below to apply to Renew AC. Once submitted, a staff member from Habitat for Humanity East Bay/Silicon Valley will contact you.

Request For Service Form: This is an initial interest form for you to express your interest in the program. Once you submit it, staff will contact you and send an official full application which you will need to fill out if you want to move forward.

Section 1.  Homeowner Information

Applicant 1





Applicant 1 Current Address




Applicant 1 Contact Info



Format 999-999-9999

Format 999-999-9999

Applicant 2

Applicant 2




Applicant 2 Current Address




Applicant 2 Contact Info



Format 999-999-9999

Format 999-999-9999
Section 2: Contact Information


Primary Contact Info
If the Primary Contact is someone other than the Homeowner, please provide their contact info below:




Format 999-999-9999




(please list English speaker as the Primary Contact above.)


Section 3: Homeowner Priorities
What are your top 4 priorities for repair or help?




When you click submit below it may take a few moments. Please only hit the Submit button once. We’ll double check to make sure you have submitted all the necessary fields. When you've filled out any of the missing pieces, submit again.

Talk to you soon and thank you for taking the time to fill out out interest form.