Residential Applications, Swedish Canadian Village

New Residency Application

Physical Referral Form
* For applications to the Swedish Assisted Living Residence Only. Download As part of the application process, please print this document and ask the applicant's physician to complete and sign.

Desired Residence
Assisted Living ResidenceGustav Wasa PlaceSwedish Canadian Manor

Please indicate the residence you would like to apply for.

Last Name *

First Name *

Date of Birth *

Present Address*

City *

Postal / Zip Code *

Home Phone *

Email *

Message

TO ASSIST US IN THE RENTAL PROCESS WE ARE REQUESTING THE FOLLOWING INFORMATION

1. INCOME INFORMATION

I declare my monthly income and Assets are:

Old Age Security (OAS)

Canada Pension Plan (CPP)

Other Pensions or annuities

Investments Income & interest

Total Monthly Income

Assets

Bank Account

Stocks & Bonds

Equity in Property

Estimated value of Assets

2. CURRENT HOUSING

Do you:

Need To Sell your home

Rent

Currently Stay with Relatives

Are you able to move without notice?
YesNo

How long have you lived in British Columbia?

3. HEALTH CONDITIONS OR DISABILITIES
Do you:

Do you have any health or disabilities concerns that we need to be aware of?
YesNo

Do you have any special dietary needs?
YesNo

Please Describe

Name of Doctor

Telephone Number

Medical Number

4. Parking

Do you have a vehicle?
YesNo

Do you require parking?
YesNo

Do you require scooter parking?
YesNo

5. Contact Person

When I am not available, you may contact the following person(s) regarding my application.

DECLARATION AND CONSENT

I understand that my information provided in this application may be shared between BC Housing for statistical information regarding age, income and rent.
I understand that this information will not be used for any other purpose than to consider my application for Supportive Housing.
I understand the person I have designated as my contact person may be contacted regarding this application.
I agree that my Landlord may be contact to provide information regarding my tenancy.

Residential Applications

New Residency Application

TO ASSIST US IN THE RENTAL PROCESS WE ARE REQUESTING THE FOLLOWING INFORMATION

Enquiries

Contact

Residences

Assisted Living Residence

Gustav Wasa Place

Swedish Canadian Manor