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Aldebrain Tower

ADMINISTRATIVE OFFICE

2155 Lawrence Avenue East, Scarborough, Ontario, Canada, M1R 5G9

Telephone: (416) 285-5447 | Fax: 416-285-1057

Part A: Date of Application

Date of Application

Part B: Housing Needs

Number of Bedrooms

1 Bedroom2 Bedroom3 Bedroom4 Bedroom

2 Bedroom with Support Services3 Bedroom with Support Services

Part C: Name & Address

Last Name

First Name

Street

Apt #

City

Province

Postal Code

Home Phone #

Work Phone #

Part D: S.I.N. & Citizenship & Marital Status

Social Insurance Number

Date of Birth

Are you a Canadian Citizen?

YesNo

If no, what is your citizenship?

Part E: Co-Applicant(s)

Do you have any co-applicant(s)?

YesNo

Name of Co-Applicant

Date of Birth

Sex

SIN

Name of Co-Applicant

Date of Birth

Sex

SIN

Part F: Child(ren)

Do you have any children?

YesNo

Name of Child

Date of Birth

Sex

SIN

Name of Child

Date of Birth

Sex

SIN

Name of Child

Date of Birth

Sex

SIN

Name of Child

Date of Birth

Sex

SIN

Part G: Family Member(s)

Will there be other family members residing in the accommodation being applied for?

YesNo

Name of Family Member

Date of Birth

Sex

SIN

Name of Family Member

Date of Birth

Sex

SIN

Name of Family Member

Date of Birth

Sex

SIN

Name of Family Member

Date of Birth

Sex

SIN

Part H: Present Accommodations

If Other, please specify

How many bedrooms?

1234

Do you have rent subsidy?

YesNo

Do you have a lease?

YesNo

If yes, what is the expiry date?

Cost of Accommodation

Per WeekPer Month

Rent

Heat

Water

Parking

Total

Part I: Current Landlord(s)

Applicant's Current Landlord

Address

City

Province

Postal Code

Phone Number

How long have you been at your current address?

Years

Months

Co-applicant's Current Landlord

Address

City

Province

Postal Code

Phone Number

How long has the co-applicant been at their current address?

Years

Months

Part J: Previous Addresses

Applicant

Address	From	To	Reason For Leaving
				×

(1)

Co-Applicant

Address	From	To	Reason For Leaving
				×

(1)

Part K: Present Employer

Applicant's Current Employer

Address

City

Province

Postal Code

Supervisor

Telephone

Occupation

Length of Employment

Full TimePart TimeShifts

Number of Hours Per Week

Co-applicant's Current Employer

Address

City

Province

Postal Code

Supervisor

Telephone

Occupation

Length of Employment

Full TimePart TimeShifts

Number of Hours Per Week

Part L: Previous Employment History

Applicant's Employment History

Employer	Position	From	To
				×

(1)

Co-Applicant's Employment History

Employer	Position	From	To
				×

(1)

Part M: Household Income

Please enter the gross monthly amount received (before deductions) from each applicable source:

Applicant's Sources of IncomeAll amounts in CAD

Court Settlement	Disability Insurance	Employment	Family Benefits Allowance	General Welfare Assistance	Old Age Security	Interest on Personal Savings	Unemployment Insurance	Other -Specify
									×

(1)

Co-applicant's Sources of IncomeAll amounts in CAD

Court Settlement	Disability Insurance	Employment	Family Benefits Allowance	General Welfare Assistance	Old Age Security	Interest on Personal Savings	Unemployment Insurance	Other -Specify
									×

(1)

Other Household Members' Sources of IncomeAll amounts in CAD

Court Settlement	Disability Insurance	Employment	Family Benefits Allowance	General Welfare Assistance	Old Age Security	Interest on Personal Savings	Unemployment Insurance	Other -Specify
									×

(1)

Part N: Child Care Expense

For employed applicants or applicants attending an educational institute on a full-time basis

Place

Duration

Cost Per Week ($)

Cost Per Hour ($)

Cost Per Month ($)

Part O: Social Assistance

Complete only if in receipt of municipal welfare or family benefits

Name of Worker

Telephone

Office Address

Part P: Assets

Do you have any assets?

YesNo

For all the assets that you own from the list below, please state the approximate values (amounts) and the amount of additional monthly income (if any) that they generate (e.g. interest, annuities, dividends)

Bank Accounts

Balance ($)

Monthly Income ($)

Trust Companies/ Credit Unions

Balance ($)

Monthly Income ($)

Bonds/ Saving Certificates

Balance ($)

Monthly Income ($)

Annuities/ Shares/ Securities/ Stocks

Balance ($)

Monthly Income ($)

Real Estate

Value ($)

Monthly Income ($)

Business Interest

Amount ($)

Monthly Income ($)

Other - Specify

Amount ($)

Monthly Income ($)

Part Q: Bank/ Property/ Business

Name of Bank	Address	Account Type	Account#	Balance ($)
					×

(1)

Do you own any property?

YesNo

Please provide more information about the property type, value and location

0 /

Do you have an interest in a business?

YesNo

Please provide more details

0 /

Part R: Pets

Do you own any pets?

YesNo

Does your pet(s) wear an identification tag and collar?

YesNo

Is your pet(s) licensed in accordance with the City of Scarborough By-Law Number 22992?

YesNo

Has your pet(s) received their annual shots and vaccines?

YesNo

What kind of pet(s) do you own?

DogCatOther

Please specify your type of pet

Please provide a detailed list with the name of the veterinarian, the telephone number of the veterinarian, the type of annual shots and vaccines your pet(s) received and the dates shorts and vaccines were administered. Please provide photocopies of veterinarian certificate(s).

Name of Veterinarian	Telephone Number	Type of Shot/Vaccine	Date of Vaccine
				×

(1)

IMPORTANT NOTICE: ANYONE WITH A PET IS OBLIGATED TO MEET ANY AND ALL CONDITIONS AS SET FORTH BY THE CITY OF SCARBOROUGH, IN CONJUNCTION WITH BY-LAW 22992. ANYONE WISHING FURTHER INFORMATION ON THE BY-LAW CAN WRITE TO SCARBOROUGH ANIMAL CONTROL, 821 PROGRESS AVENUE, SCARBOROUGH, ON, M1H 2X4 OR CALL THEM AT (416) 396-7387.

Part S: Emergency Contact(s)

Please list your emergency contacts below. In addition, please also list the information of your family physician.

Name	Address	Telephone	Relationship
				×

(1)

Part T: References

Please provide three (3) references. Do not use family members as references

Name	Address	Telephone	Relationship
				×

(1)

Part U: Declaration

PLEASE READ AND SIGN THE FOLLOWING DECLARATION FORM.

I/We hereby declare that all statements made in the foregoing application are correct, accurate and complete. I/We also agree to provide Aldebrain Attendant Care Services of Toronto with any documentation requested, in order to substantiate any statements made within this application.

I/We fully understand that this application and any supporting documents provided, or that may be requested will become the property of Aldebrain Attendant Care Services of Toronto.

I/We understand that Aldebrain Attendant Care Services of Toronto, or any agent(s) assigned may check the information provided, and may also contact the support agency(ies), or contact any person(s) named in order to verify any information. I/We further understand that the information provided will facilitate a credit check; and I/We hereby consent to a credit check and authorise Aldebrain Attendant Care Services of Toronto to request and obtain any additional information from any of the agency(ies) or party(ies) named in this application.

I/We further understand that this application does not constitute an agreement on the part of Aldebrain Attendant Care Services of Toronto to provide me/us housing; and I/We further understand that only those individuals who have been identified in part E (Co-applicant(s)); Part F (Children); and Part G (Family Member(s)) can live at Aldebrain Attendant Care Services of Toronto.

I/We further understand that if, at any time, it comes to the attention of Aldebrain Attendant Care Services of Toronto that any, or all of the information provided was incorrect, inaccurate or incomplete, or has been falsified in any way, that this will be the cause for my/our lease to be terminated.

I/We fully understand and agree that Aldebrain Attendant Care Services of Toronto is based on the concept of "Neighbour Helping Neighbour" and will conduct myself/ourselves accordingly.

Witness

Applicant

(Sign Here)

Clear Signature

Date

Witness

Applicant

(Sign Here)

Clear Signature

Date

ALL INFORMATION IS KEPT STRICTLY CONFIDENTIAL

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