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Date : ___________________

Job # ___________________

The undersigned owner of a residence located at:

Street Address _________________________________________

City/ State/Zip Town ______________________________________________________

Authorizes the Hope Builders Ministry of the Pittsylvania Baptist Association Inc. and its volunteers to do work on facilities on their property. The undersigned owner does not hold Hope Builders or the Pittsylvania Baptist Association and its volunteers responsible for any damage that may occur to the residence.

Hope Builders and the Pittsylvania Baptist Association volunteers will not accept payment for their labor or services. If you wish to make a contribution please feel free to contact us at the phone number below. The homeowner is responsible to provide any building materials that may be needed. Hope Builders Ministry of the Pittsylvania Baptist Association agree to do as much of the following work as as is possible.

The volunteers are fully insured through the Hope Builders Ministry of the Pittsylvania Baptist Association and/or its partners.

Please indicate and describe work that is needed at the residence:

____________________________________________________________________________________________

The owner hereby certifies that this is his/her residence and that he/she agrees to either personally approve (or to designate someone to approve) all work at his /her residence while it is being done.

Owner Phone ______________________________

Owner Name (print) ___________________________________

Signature ___________________________________________

Date __________________

Hope Builders
A Ministry of Pittsylvania Baptist Association Inc.
186 Deer Run Road
Danville , Virginia 24540
(434)792-7678 pba.47@verizon.net