147 – 1300 Parkgate Avenue North Vancouver, BC, V7H 2Y2 Tel: (604) 929-9499 Fax: (604) 929-9404 Email: mslhs@telus.net Web site: www.mountseymourlions.org

Application for Senior Housing – Lions Libby Lodge Lions Manor

1. Please list all persons who would be residing in this housing unit should this application be accepted. You will be required to provide identification for all persons listed on this application prior to being accepted for any of our units.

Name Date of Birth Day Month Year  1.   2.

2. Please provide all current phone numbers in order of preference.

1.   2.   3.   4.

3. If you would prefer to correspond via email, please provide your email address.

4. Please provide your current address. If you do not have a permanent address, please provide an address that we can use to mail you any information or updates.

5. Please advise what type of accommodation you are requesting.

Type  Lions Libby Lodge  Lions Manor  Bachelor  Not available  1 Bedroom Single  1 Bedroom Double  Wheelchair accessible

Please be advised that pets are not permitted in Lions Libby Lodge or in Lions Manor.

6. Please provide the following information on your income. Paperwork verifying this information would be required should you be accepted for one of our units.

Applicant 1.  Source of Income  Gross Monthly Income

Applicant 2.  Source of Income  Gross Monthly Income

7. Please provide the following reference information.

Present Landlord  Phone number  How long there?  Rent paid

Previous Landlord  Phone number  How long there?  Rent paid  Why did you move?

8. Please provide the reason(s) why you want to move from your present address.

9. Are you required to provide one months notice to your present landlord?

Yes     No

10. Please provide the following information on your vehicle. Parking is limited and subject to availability.

Model   License Plate #

11. DECLARATION

I/We declare that the information supplied on this application is true and correct. I/We understand that this application does not constitute an agreement on the part of the MOUNT SEYMOUR LIONS HOUSING SOCIETY to provide me/us with rental accommodation and that this application might not be retained by the MOUNT SEYMOUR LIONS HOUSING SOCIETY once the application has been reviewed for a particular housing project. For the purpose of assessing this application, I/We hereby consent to allow the MOUNT SEYMOUR LIONS HOUSING SOCIETY permission to obtain credit and/or personal reports on me/us from one or more agencies or individuals. I/We hereby authorize agencies or individuals to provide whatever such information they may have to the MOUNT SEYMOUR LIONS HOUSING SOCIETY relative to an assessment of this application.

12. Please print your full legal name(s).

14. Signature:

Please note: submitting on-line does not constitute a signature – you will be asked to sign an original application before commencing your tenancy.

2007 – 2008 RENTAL RATES SENIOR HOUSING

Lions Libby Lodge        All units are Rent Geared to Income Lions Manor        All units are Rent Geared to Income