Housing Application Electronic Form

Housing Application

Please complete this form to be considered for our affordable housing for Seniors and people living with disabilities.

"*" indicates required fields

What building is this application for?*

Golden Vista (375 Cherry Avenue, Kamloops)

Meadow Creek (278 Alder Drive, Logan Lake)

Both

Name (First and Last)*

Please provide your full name

Date of Birth*

Email*

Home/Cell Phone Number*

Please provide a phone number you can be reached at.

Second Person Name (First and Last)

Second Person Date of Birth

Home/Cell Phone Number

Current Address*

Street Address Address Line 2 City Province Postal Code

BC HOUSING REGISTRY NUMBER (Not mandatory to apply but you must be on the registry before a housing offer can be issued)

You can email adam.burrows@cmha.bc.ca or call at 250-374-0440 ext.206 to add your registry number later.

Residence History

Please list your last two adresses.

Previous Address and Landlord Information #1*

Please fill this box in with your last address and the time period you stayed there. (From date _______to date _______), Name of Landlord, Landlord Phone Number

Previous Address and Landlord Information #2

Please fill this box in with your last address and the time period you stayed there. (From date _______to date _______), Name of Landlord, Landlord Phone Number

Income Information

List all members of your household

Income*

First Name

Source of Income

Gross Monthly Income

Reason for move

Are you under notice to end your present tenancy?*

Yes

If yes, please attach a copy of the notice from your landlord

Max. file size: 300 MB.

If you are not under notice, why do you wish to move?

Please be specific

References*

Name

Title (Landlord, family, support worker, etc.0

Phone Number

Please provide 3

Do you have any pets?

If yes, how many and what type?

Declaration: Please read and acknowledge this statement

I/We declare: – This is my application – All the information in it is correct and complete to the best of my knowledge and belief I/We authorize: – Pursuant to the Freedom of Information Act and Protection of Privacy Act (the FOI Act), CMHA Kamloops to make any inquiries that are necessary to verify the information given in this application; and – Pursuant to the FOI Act, any person, corporation, or social agency to release CMHA Kamloops any information pertinent to the assessment of my/our application; and – CMHA Kamloops to receive and exchange with credit bureaus and our my/our previous landlords credit and other information about me/us, to be used in the decision making process to provide me/us with rental accommodation. I/We understand: – That this application does not constitute any agreement on the part of CMHA Kamloops to provide me/us with rental accommodation; and – that it is my/out responsibility to advise CMHA Kamloops of any changes to the information given in this application and to provide ay supporting materials required for my/our application.

I agree

I disagree