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HOME COnnection
Application
This site is secure and your information will remain confidential.
CONTACT INFORMATION
All fields marked with an Asterisk(*) are required.
Last Name*
First Name*
Middle Initial*
Home Phone Number*
Work Phone Number*
Address*
City*
Province*
Postal Code*
PERSONAL INFORMATION
Gender Identity*
He/Him
She/Her
They/Them
Date of Birth*
Age*
What is your Canadian Status?*
Canadian Citizen
Permanent Resident
Other
Are you currently enrolled in Post Secondary School?*
Yes (Part Time)
Yes (Full Time)
No
Are you currently living in St. Albert? *
Yes
No
Why are you applying?*
CURRENT HOUSING Information
Start of Occupancy*
Number of Bedrooms*
What utilities do you pay?
Power
Heat
Water
Cost of Rent*
Do you have a tenancy agreement?*
Yes
No
Current Landlord Information
Name*
Phone*
Address*
City*
Province*
Postal Code*
Occupant(S) Information
List all the household members who are living with you (children, common-law partner, live-in aide)
First and
Last Name
Relationship to
Applicant
Gender
M/F/O
Date of Birth
MM/DD/YY
Is this person a full-time student?
Occupant 1
Occupant 2
Occupant 3
Occupant 4
Occupant 5
If you have Children, do they live with you continuosly?
(Yes/No)
If no, please explain.
Do you have a pet?
Dog
Cat
Other
If you have a support worker or other support service agency worker and you wish to provide their contact information please complete below:
Support Worker
Agency
Contact Number
Support Worker 1
Support Worker 2
Support Worker 3
Financial INFORMATION
Employment information
Employer
Dates of Employment
Hours/Week
Salary
Company 1
Company 2
other income sources
Employment
AISH
Alberta Works Income
Employment Insurance
Alberta Child Benefit
Child/Spousal Support
Disability Benefit
Alberta Tax Benefit
Student Loans/Grants
Workers’ Compensation
Other
Other assets
Amount in the Bank
Other
Vehicle Information
Make
Model
Monthly Payment
REQUIRED AKNOWLEDGEMENTS
I/we understand that this application does not constitute an agreement on the part of the St. Albert Housing Society to provide me with rental accommodation or rent subsidy.*
I/we authorize the St. Albert Housing Society or its agents to make any inquiries to any organization orindividual to verify information regarding my/our household composition, income, employment or address.*
I/we consent to the St. Albert Housing Society or its agents contacting any of my/our current or perviouslandlords to complete reference checks for the purpose of assessing my/our suitability as a prospective tenant.*
I/we also release and save harmless the persons and organizations from any and all claims, actions, demand,damages and expenses in connection with or arising out of such release of information to the St. Albert Housing Society.*
I/we understand there may be legal penalties for providing false, misleading or incomplete documents on which the St. Albert Housing Society relies to determine my/our eligibility for rental accommodation or rentsubsidy and/or to calculate my/our benefit of rent-geared-to-income.*
Thank you! Your submission has been received!
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I WANT TO DONATE
I AM IN NEED OF HOUSING
I AM AN ADVOCATE
The St. Albert Housing Society is funded in-part by
The Friends of St. Albert Housing Society Charity
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