ATION FOR RENTAL ACCOMMODATION
MARKET APPLICATION FORM
I am requesting a (check all that apply):
Studio
Please indicate Unit # if known: __________ OR:
1 Bedroom
2 Bedroom
3 Bedroom
4 Bedroom
Preferred Location (check all that apply):
Hidden Creek
Kew Court
Larchwood
The Pacifica
The Wing
Queens Court
Tamarack Close
Applicant Information (19 and older)
Applicant A:
Name:
Phone:
(Home)
(Other)
Driver’s License Number:
Social Insurance Number:
Marital Status (check one):
Single
Single Parent
Married
Common-Law
Applicant B:
Name:
Phone:
Social Insurance Number:
(Home)
(Other)
Driver’s License Number:
Accommodation Required:
Do you have any special requirements? If yes, please summarize:
Do you require a wheelchair modified unit? Yes
No
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Pets:
Do you have pets? Yes 
No 
If yes, please specify:
PLEASE NOTE:
 NO Cats or Dogs permitted in Hidden Creek, Kew Court, Larchwood or Tamarack Close with the
exception of Certified Guide Dogs.
 TWO spayed/neutered, indoor cats OR dogs less than 20 pounds are permitted at THE WING.
 ONE spayed/neutered, indoor cat is permitted at the PACIFICA. Pets are not permitted at QUEENS
COURT. Where applicable, Pet Damage Deposits will apply.
*There may be exceptions to pet size (dogs) on the first floor of The Wing, made at the landlord’s discretion and pending
three written character references. If the dog exceeds the 20 pounds, only one dog will be permitted.
Household Information, Please list yourself on Line 1 and then the remaining applicants:
Name
Date of Birth
(Surname, Given Name)
(Month, Day, Year)
1.
Sex
Relationship to Applicant
(M/F)
Applicant
2.
3.
4.
5.
6.
Rental/Residency History, List Addresses for AT LEAST the past 2 years:
From
Address
(Month, Year)
To
(Month, Year)
Landlord’s Name
Landlord
Phone Number(s)
Current Accommodations:
Current monthly rental/mortgage payment:
Does your rent include:
Heat? Yes 
No 
Hydro? Yes 
No 
Reason for vacating current accommodations:
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Income Information, List gross monthly income for all Household Members:
Source
Name
Monthly Income
(Example: Employment/Employer Name, EI, CPP, Pension, Child Support etc.)
$
$
$
TOTAL HOUSEHOLD MONTHLY INCOME: $
DO NOT INCLUDE: Child Tax Credit, GST, SAFER Payments
PLEASE NOTE:
Tenants applying for the second and third floor of The Wing must show that their gross annual
household income is within $30,000.00 to $54,000.00.
Household Vehicles:
Do you require parking space(s): Yes 
No 
If Yes, how many?
Vehicle Make and Model
Year
License Plate Number
PLEASE NOTE: Parking is not included in rent at some locations
Character References:
Do NOT include friends or family as character references, acceptable character references are employers, supervisors,
co-workers and social workers etc.
Name of Reference
Relation to Applicant
Reference Phone Number(s)
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Declaration:
I/We certify that the information in this application is true, correct and complete in every respect to the best of my/our
knowledge and can be verified by Pacifica Housing including obtaining credit and/or personal repots on me/us from
one or more agencies or individuals.
I/We hereby authorize agencies or individuals to provide whatever information they have to Pacifica Housing relative
to the assessment of the application.
I/We understand that this application does not constitute an agreement on the part of Pacifica Housing to provide
me/us with rental accommodation.
If you are submitting this form electronically, you must print this page and either fax or scan and send by
email to [email protected]
Signed (Applicant A)
Date
Signed (Applicant B)
Date
Before submitting Application, please ensure that you have done the following:
□
□
□
Completed application in full
Attached current income verification for all household members (dated within past 3 months)
Read declaration and signed application in space provided above
If submitting Application online:
□
□
Print page 4 of 4, sign (all applicants), and fax to 250-385-6776 or scan and send by email AND
Continue to submit your completed application in full electronically by clicking the Submit button, or email
to: [email protected]
Print
Submit
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