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Please list your address(es) for the past 3 (three) years. Must be completed.
Have you at any time lived in Social Housing? ☐ Yes ☐ No
If yes, what was the organization? _____________________________________________________________________
What were the dates of residency? From ________________ To ________________
Please describe your current accommodation as completely as possible by completing the information below.
☐ Basement Suite
☐ Couch Surfing
☐ Emergency Shelter
☐ Housekeeping Room
☐ Living with family members
☐ Room & Board
☐ Single family dwelling
Number of Bedrooms:
☐ Share Expenses
☐ Have Free Accommodations
☐ Other: ______________________________________
Does your current accommodation have:
Do you have any household pets?
Have you been given a “Notice to End Tenancy”? ☐ Yes ☐ No
If yes, please attach a copy of the “Notice to End Tenancy” from your landlord.
If you are not under Notice to End Tenancy, why do you wish to move? (Please be specific)
APPLICANT SIGNATURE: (Please read and sign this statement)
I understand that this application does not constitute any agreement on the part of Lu'ma Native Housing Society to
provide me with rental accommodation. I hereby certify that the information given in this application is true, correct,
and complete in every respect to the best of my knowledge and will be verified, if so required by Lu'ma Native Housing
Society. I understand that it is my responsibility to advise Lu'ma Native Housing Society of any changes to the
information given above.
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