Purcell View Apartments - Application Form

If this application is printed, please return the completed application to Golden CED at PO Box 746, Golden, BC, V0A 1H0 or drop it off at 202-421 9th Ave. N (slide it under the door if closed).

Full Name*

First NameLast Name

Date of birth*

DayMonthYear

Phone Number*

Area CodePhone Number

E-mail*

example@example.com

Address*

Street Address

Mailing Address

CityProvince

Postal Code

How long have you lived in BC?*

How long have you lived in the Golden area?*

Marital Status*

Spouse's Name

Do you have a disability?*

YesNo

State the particulars of your disability

General state of health*

Who is your regular doctor?*

Total monthly income including all pensions, OAS, CPP, DVA, etc.:*

Do you qualify for any income supplements?*

YesNo

Do you own real estate?*

YesNo

Assessed value

Location

Do you have any other assets (ex: savings, investments)?*

YesNo

Value

Describe your present accommodation*

Amount of rent*

Why do you wish to move?*

Please provide two references:*

	Full Name	Contact Number
1
2

Alternate contact in Golden (if we cannot reach you when a unit becomes available):*

	Name	Phone Number	Email	Relationship
Alternate contact

In signing this application, I agree to the following terms and conditions (check all boxes):*

This application doesn’t guarantee placement in a unit. When a unit becomes available, there will be a selection process including an eligibility assessment.This is an independent living facility and as such I must be capable of caring for myself, as no services are provided. If my health (or that of my spouse) requires nursing care or if I or my spouse are deemed by Golden CED to be putting other residents or the building at risk, then I may be required to move out of Purcell View Apartments.All residents of Purcell View Apartments are required to have a local emergency contact.This is a non-smoking building and no smoking in the building or individual apartments will be tolerated.I understand that I must be prepared to acquire furnishings suitable for my unit.All rental rates are determined at the time of unit assignment.

Date application is submitted

DayMonthYear