Apply for Residency - Pan Am Place

SECTION 1

Name of Applicant

Current place of residence

Date of birth

Contact phone number

Contact E-mail

Support Worker Contact Number

Support Worker Contact E-mail

Agency

SECTION 2

Briefly describe why you are in need of an alternate residence, and more specifically, why have you chosen to apply to Pan Am Place?

SECTION 3 HOUSING

Where, and with whom are you currently living? How long have you lived there?

Is this a stable environment? Please explain why you feel this way.

Do you feel safe where you are living now? If not, please identify why.

Are you currently living with anyone experiencing alcohol or drug issues/dependency?

EMPLOYMENT & EDUCATION

Do you have a source of income?

Yes
No

If YES, please disclose the amount

Are you currently receiving EI payments?

Yes
No

If YES, please disclose the amount

Are you currently receiving a disability pension?

Yes
No

If YES, please disclose the amount

Are you in receipt of any other form of funds?

Yes
No

If YES, please disclose the amount

Are you legally entitled to work in Canada?

Yes
No

What is your current employment status?

Full Time
Part-time
Not working (not currently seeking employment)
Student
Unemployed (currently seeking employment)

Date last employed

Longest period of employment

If you are employed, who is your employer, and what is your current position?

Highest level of education completed

What date did you last attend/graduate?

Reasons for not continuing with your education

Do you plan to continue your education in the future? Please explain your answer.

DO YOU CURRENTLY VOLUNTEER YOUR TIME? IF SO, PLEASE COMPLETE THE SECTION BELOW.

Organization

Contact person

Time commitment (hours per week)

Main duties

RELATIONSHIPS

Please select the relationship status that best reflects your current situation

Length of your current relationship

Do you have any children? If yes, how old?

If you have children, what is your custody status?

Sole
Joint
No custody

Are you currently the primary caregiver for a child or other relative?

PERSONAL HISTORY

All applicants must undergo a criminal record and a child abuse registry check. A criminal record does not necessarily disqualify the applicant from residency, but will be used to confirm an applicant’s declaration.

Have you ever self-harmed or attempted suicide? If yes, is this a current concern?

Have you ever been charged with a violent offence? If yes, please explain.

Are you currently on probation?

Yes
No

Expiry date

* If applicable please attach a copy of conditions/court order.

Max. file size: 2 MB.

IF YES, PROVIDE THE NAME, ADDRESS, AND PHONE NUMBER OF CONTACT.

Officer

Address

Phone

Email

SECTION 4 IDENTIFICATION

Please identify which forms of identification you currently possess, and note those needed.

MHSC

Has
Needs

Birth Certificate

Has
Needs

S.I.N.

Has
Needs

Photo I.D.

Has
Needs

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