Name*

Phone*

E-mail

Address1

Address2

City

State

Zip

In a housesharing situation would you be interested in living with (check all that apply):
Adults
Children
Teens
One Person
A Family
Men
Women
Cats
Dogs

Do you smoke? (check one)
Yes
No

Are you interested in renting (check all that apply):
in 1-3 months
in 3-6 months
in 6 months to 1 year
1 or more years from now

What interests you about cohousing?

Is there anything else you would like us to know about you?

*You must fill in fields marked with an asterisk before submitting this form.