Rental ApplicationApply NowAt Bethania Mennonite Personal Care Home we strive to provide the highest quality of care to all of our residents. To apply for tenancy with Bethania please fill out this online form. Step 1 of 3 33% Location(Required)Select One ---285 Pembina529 Country Club BlvdArlington HausBethania HausFred Tipping PlaceKingsford HausHousehold Member InformationPlease provide personal information below for all the people who will live in the household including you the applicant.Name(Required) First Middle Last Date of Birth(Required) MM slash DD slash YYYY Status in Canada(Required)Select One ---PermanentTemporaryMain Phone(Required)Additional PhoneAdd an additional Member Yes Second Member Name(Required) First Middle Last Second Date of Birth(Required) MM slash DD slash YYYY Second Status in Canada(Required)Select One ---PermanentTemporaryHome Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Main Phone(Required)Additional PhoneMain ContactContact Name(Required) First Last Contact Phone(Required)Contact Email(Required) Contact Organization(Required)Do you:(Required) Own Rent Live with Family What is your current mortgage payment?(Required)Do you need Parking?(Required)YesNoDo you have Pets?(Required)YesNo Housing HistoryPlease provide 2 housing histories for each of the applicants.First Housing Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code First Landlord Contact First Last First Contact PhoneFrom Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Was this Manitoba Housing?YesNoSecond Housing Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Second Landlord Contact First Last Second Contact PhoneFrom Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Was this Manitoba Housing?YesNoMonthly Income for ApplicantSelf Employment/Employment IncomeEmployment Income AssistanceDisability IncomeRetirement Income - CPPPension, RRSP,RRIFAlimonyApplicant Total Gross Monthly IncomePlease list total net value of any assets:Savings, Investments, PropertyMonthly Income for Co-ApplicantSelf Employment/Employment Income 2Employment Income Assistance 2Disability Income 2Retirement Income - CPP 2Pension, RRSP,RRIF 2Alimony 2Applicant Total Gross Monthly Income 2Please list total net value of any assets 2:Savings, Investments, Property Medical Information is VoluntaryDo you have any health problems Bethania needs to be aware of? Yes No Please list health problems:Will you have homecare? Yes No Next of Kin or Emergency Contact Person(s)Contacts(Required)NameRelationshipPhoneEmail Add RemoveEmployment & Income AssistanceIf you receive Employment & Income Assistance, please provide the following information:Case-worker First Last Case NumberPhoneSpecial CircumstancesPlease answer the following questions. If you check any of the options below, you may need to provide at a later date the required documents listed beside the question when you submit your application.Special Circumstances Homeless? (living in a shelter, on the street or in the hospital) Temporarily sheltered and at risk of homelessness? (staying at family or friends, hotel, hostel or transitional immigration centre) An individual with a disability who is being forced to leave their current home within the next three months? Needing to move due to family separation, loss of a caregiver or unsafe housing conditions? Disabled and unable to work for 12 months or longer? Requiring accessible housing to accommodate household members with physical disabilities? Is this application is being submitted on behalf of a person who is registered with the Public Trustee? Yes Trustee Contact Name(Required) First Last Trustee Contact Phone(Required)Message
