Housing Application - online

Name *

Date of Birth

Gender

Do you identify as an Indigenous person of Canada?

Yes

No

Prefer Not to Answer

Citizenship

Language Spoken

BC Housing Number

Do you have a pet?

If yes, what kind?

A pet application must also be completed

Relationship Status

Is there any past or present ongoing intimate partner conflict you wish to disclose?

if yes, please explain

Do you have children/dependents under 19 years of age?

Yes

No

if yes, please specify

Do you expect an increase or decrease in the number of children in your care over the next 2 years?

if yes, please explain expected changes

Number of bedrooms required

Address

suite/house number and street

City/Town

Postal Code

How long have you been there?

Telephone Number

Email Address

If you do not have reliable means for contact, is there anyone we can leave a message with in order to contact you?

If we are unable to contact you, we will not be able to process your application

Please select one of the options that best describes your current living situation

Is there a deadline to leave your current living situation?

if yes, what is the date?

What are the reasons for moving?

Do you or your children have any special housing needs, or a pre-existing medical condition that would affect your housing needs?

Please include any mobility, hygiene, or health concerns that may influence the type of housing needed

Employment Status

Income Source

Total Monthly Income

Assets: Please list current value of all assets held by you and the members of your household

Cash/Bank Balance, Savings, Value of Real Estate Owned, Value of Vehicles Owned, Number of Vehicles Owned

Do you have a vehicle?

Current Supports Network: Please list all supports, personal and professional, for yourself and your children

Contact or Organization name, phone, email

Are there Community Resources you would like to be connected with?

Contact or Organization Name (if known), brief description of Services you are looking for.

Where do you go for healthcare?

Accessibility Needs

Are you currently looking for support for substance use?

If yes, what sort of supports?

Do you have any legal issues going on currently?

if yes please describe

Do you have any government issued Identification?

If Yes, which ones?

What type of housing are you applying for?

How did you learn about the program?

if other, please specify

Signature and Declaration - click ? to read

Please Sign Here. Sign directly in the large box or type your name in the box below

Date signed

Content Type

Attachments:

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