HOUSE OF PEACE
Neighbour Application
211 EDMONTON STREET, WINNIPEG, MANITOBA R3C 1R4 (204)942-5535
Full Name Date of Birth
SIN # Phone
Email Country of birth
Arrival to Canada ________________________________ Arrival to Manitoba _______________________
Are you studying? ________________ working? _____________
Present Address
Landlord Phone No.
How long have you lived here (years/months) Monthly Rent $
Previous Address
Landlord Phone:
How long did you live here (years/months) Monthly Rent $
Present Employer Gross Monthly Income $
Address: Your position:
Supervisor’s name: Phone:
How long have you worked here: _ (years/months)
Previous Employer Gross Monthly Income $
Address Your position
Supervisor’s Name: Phone No.
How long did you work here: (years/months)
1
Additional Reference:
Name: Relationship:
Phone #: Email:
Emergency contact person: Relationship:
Phone number: Email address:
Do you have allergies or medical condition which requires medication or supervision?
_______________________
Damage deposit: $50.00 to be paid after 3 months at HOP. This will be returned upon
leaving if one month’s notice is given and if the room is left the way it was originally
found.
I hereby declare that the statements and information provided in this application
are, to the best of my knowledge, true and accurate and that no relevant
information has been withheld. I authorize and give my consent to the securing of
any information, records, or documents from any source as may be deemed
necessary in conjunction with this application.
Signature Date
Other Documentation Required
You will need to provide copies of the following documents:
Two pieces of I.D. with photo (e.g. driver’s license, passport, PR card)
Manitoba Health Card
Tax assessment letter with Line 150 (from previous year) if applicable
Permanent Resident Card (if
applicable) Source of Income:
Three latest pay stubs (if employed) OR
Letter of employment stating number of hours working and rate per hour or salary (if employed)
EIA Budget Letter OR EI Report with start and end dates (if unemployed)