File No ___________
APPLICATION FORM
AMICAE HOUSING CO-OPERATIVE
#800 – 1047 Barclay Street
Vancouver, BC, V6E 4H2
PLEASE READ THROUGH THE INSTUCTIONS CAREFULY
INCOMPLETE OR IMPROPERLY FILLED APPLICATIONS WILL NOT BE CONSIDERED
1) Applicant Information:
Cetina
Last Name: _________________________________ First Name: Clemencia
__________________________________
Dic 13, 1985
Date of Birth: _______________________________________________ Female
Gender: _____________________
Canadian citizen
Status in Canada: ___________________________________________
Andres Blanco
2) Contact Information:
You must currently reside in British Columbia in order to be eligible for consideration
1039 Burnaby st
Current Address: __________________________________________________________________________
City: Vancouver
________________________ BC
Province: ____________________ V6E1N9
Postal Code: __________________
Phone Number: 7882303259
______________________________ Secondary Number: 604-445-2421 (husband)
___________________________
[email protected]
Email: ___________________________________________________________________________________
3) Household Information:
In order for your application to be considered, all household members applying with you must currently reside in British
Columbia and must be a Canadian citizen/Permanent Resident. Use (C) to indicate Citizen or (PR) to indicate Permanent
Resident under “Status”.
Name Relationship DOB Gender Status
Applicant Name: Self
1) Clemencia Cetina Wife 85-Dic-13 Female C
2) Andres Blanco Husband 82-Jun-9 Male C
3) Ada Eloise Blanco Cetina Daughter 22- Jul- 17 Female C
4) Clemencia alcantar My mother 1960 Nov 7 Female
Do all of the people listed above live with you full time? Yes: _____________ No: _____________
If No, please provide the following information for all persons not living with you full time.
Name Days per week Reason
1)
2)
3)
4)
Page 1 of 5
4) Housing Needs
Please indicate the amount of bedrooms you would like to apply for. You may check more than one option.
1 Bedroom Use the following standards to determine the appropriate sized unit for your household.
Please note that you will not be considered for a unit with more bedrooms than your
2 Bedrooms household is entitled to.
3 Bedrooms
- All bedrooms must be occupied by a member of your household
- Spouses and couples are entitled to one bedroom only
Locker - Dependants are entitled to one bedroom each
- You are entitled to an extra bedroom if you require a live-in caregiver
Parking Space
Does your household include pets? If Yes, please specify: ____________________ How many? _____________
Amicae has multiple units designed with accessibility in mind. Please specify if you require accessibility features,
such as wheelchair access, adapted kitchen/bathroom, live in attendant, etc: _____________________________
__________________________________________________________________________________________
If an accessible unit is not available, would you like to be considered for a standard unit? Yes: ______ No: ______
5) Residence History
Please provide information on where you have lived for the past 5 years.
1039 Burnaby st unit 14
1) Address: ___________________________________________________ Dates: 2016- Jan- 01
____________________
Landlord: Carlos - Francis Drake Apartments
___________________________________________________ Phone: ____________________
(236) 591-5368
2) Address: ___________________________________________________ Dates: ____________________
Landlord: ___________________________________________________ Phone: ____________________
3) Address: ___________________________________________________ Dates: ____________________
Landlord: ___________________________________________________ Phone: ____________________
4) Address: ___________________________________________________ Dates: ____________________
Landlord: ___________________________________________________ Phone: ____________________
Inquiries to previous landlords will not be made without your consent. Consent: Yes: ________ No: ________
6) Employment Information
Applicant's Employment (last five years).
1) Job Title: Paver instalations - Construction
___________________________________________________ 2021- currently
Dates: ____________________
Villa Roofing
Employer: __________________________________________________ Phone:
[email protected] ____________________
2) Job Title: Paver instalations - Construction
___________________________________________________ 2019-2021
Dates: ____________________
Maroon Creations
Employer: __________________________________________________ Phone: +1 (778) 954-8182
____________________
Other Adult's Employment (last five years).
Private Tutor
1) Job Title: ___________________________________________________ 2020-2021
Dates: ____________________
Employer:Manica
__________________________________________________ Phone:[email protected]
____________________
Assistant teacher
2) Job Title: ___________________________________________________ 2018-2020
Dates: ____________________
[email protected]
Employer: Lions Gate Montessory School
__________________________________________________ Phone: ____________________
Page 2 of 5
8) Questionnaire
Why do you want to live in a Housing Co-Op?
My family seeks co-op housing support due to challenging circumstances.
_________________________________________________________________________________________
Our income relies solely on my husband's approximately $4,000 income, sometimes less.
_________________________________________________________________________________________
Our situation is compounded by our baby's severe food allergies, requiring my full attention.
Despite efforts, daycare centers have declined due to her allergies.
_________________________________________________________________________________________
Our financial struggles extend to paying our rent, placing us in a difficult position. I'm a mother in need of assistance.
_________________________________________________________________________________________
What do you believe are some advantages and disadvantages of living in a Co-op?
I_________________________________________________________________________________________
firmly believe that living in a co-op offers numerous advantages.
It_________________________________________________________________________________________
fosters a strong sense of community, support, and shared responsibilities, creating a nurturing environment for families.
_________________________________________________________________________________________
However, potential disadvantages could involve decision-making dynamics.
Despite this, I am eager to embrace the benefits of co-op living for my family's well-being and growth.
_________________________________________________________________________________________
Do you have any special skills or interests which might be helpful in the running of a Housing Co-op? If yes,
please explain:
Absolutely, my husband possesses valuable general construction knowledge, which could contribute to maintaining and
_________________________________________________________________________________________
improving the co-op's facilities. On my end, I bring administrative expertise to assist in the smooth functioning of various
aspects.
_________________________________________________________________________________________
Moreover, my involvement in gardening and organizing family-oriented activities could enhance the co-op's community
_________________________________________________________________________________________
engagement. We are enthusiastic about leveraging our skills and interests to enrich the co-op experience for all members.
_________________________________________________________________________________________
Tell us about some volunteer activities that you and your family have participated in. Give details of where, when
and what you did:
_________________________________________________________________________________________
Certainly, my family and I actively volunteer at Coastal Church.
_________________________________________________________________________________________
I serve as a school-age teacher, contributing my expertise to educate and engage young minds.
_________________________________________________________________________________________
Simultaneously, my husband dedicates his time as a musician, using his talents to enrich the church's worship experience.
Our involvement spans various roles and activities, demonstrating our commitment to giving back to the community.
_________________________________________________________________________________________
_________________________________________________________________________________________
Which committees would you be prepared to serve on?
Board of Directors Elected positions which provide overall coordination of Co-op
Finance Budget, and other financial aspects of the Co-op
Landscape General upkeep of garden areas
Membership Interviewing prospective members, maintaining member participation, etc
Social Planning social events for members, such as potluck, movie nights, etc
Maintenance Coordinating maintenance, plus general upkeep and repairs of Co-op
Please list any other information about yourself which you may like to provide:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Do you know anyone currently residing at Amicae who has agreed to provide a reference? Yes: ____ No: ____
If Yes, please provide unit number and name: ______________________________________________
Page 3 of 5
Dear Applicant,
Thank you for applying to Amicae Housing Co-operative.
Please read and initial each of the following statements. By initialling you indicate that you have read,
understand and agree to each one.
A new application form must be submitted every 12 months, or when there are
changes to household size, income, or unit preference. We do NOT accept emails or
letters indicating continued interest. CC
_____
Receipt of your application form only places you in our active applicant pool. It does not
guarantee that you will be selected or interviewed for membership. We do not provide
status updates on applications. If in doubt, simply resend your application.
CC
_____
If called for an interview, all members of household must be present, including children. CC
_____
If selected for an interview, you will be required to provide:
NOTE: DO NOT SEND THESE ITEMS UNLESS CONTACTED FOR AN INTERVIEW.
Copies of last year’s Notice of Assessment from the CRA
The three most recent consecutive pay slips
Two personal references, and two professional references
Proof of Citizenship/ Permanent Residency
A cheque or money-order for a $20 non-refundable processing fee.
(This fee will ONLY be used to complete a Credit Check for the
successful applicant) CC
_____
Amicae will contact and check landlord, personal and employment references, along
with credit histories prior to offer of membership. CC
_____
A housing cooperative is a group of people working together to enjoy long term affordable housing.
Each member has a responsibility to participate in the ongoing care and maintenance of the housing
complex. Therefore, please do not look upon Amicae Housing Cooperative as inexpensive housing
without commitment. The responsibility of membership is not for everyone.
Sincerely,
AMICAE HOUSING CO-OPERATIVE
I UNDERSTAND THAT MEMBERSHIP IN AMICAE CO-OPERATIVE WILL REQUIRE ACTIVE
PARTICIPATION AND ATTENDANCE AT ALL GENERAL MEETINGS. I AM AWARE THAT IF MY
APPLICATION IS ACCEPTED, I MUST ABIDE BY ALL POLICIES APPROVED BY GENERAL
MEMBERSHIP, AND THAT FAILURE TO DO SO MAY RESULT IN MY EXPULSION.
I HEREBY ACKNOWLEDGE THAT MY SIGNATURE ON THIS APPLICATION WILL BE
CONSIDERED AS AUTHORIZATION TO MAKE NECESSARY INQUIRIES TO PREVIOUS
LANDLORDS.
Applicant's Signature: ______________________________ Sep 2023
Date: _________________________
Other Adult's Signature: ____________________________ Date: _________________________
Page 4 of 5
File No ___________
APPLICATION FORM
AMICAE HOUSING CO-OPERATIVE
#800 – 1047 Barclay Street
Vancouver, BC, V6E 4H2
CONFIDENTIAL INCOME INFORMATION
Please print this page separately and do not staple to the rest of the application.
Name Gross Fixed Income (per year) Other Income (per year)
Applicant: $ $
1) $ $
2) $ $
3) $ $
4) $ $
5) $ $
6) $ $
7) $ $
Total gross income for household $
You must provide financial info for all members contributing to household income.
Definitions of income include but are not limited to the following:
- Gross Salary, Wages and Overtime - Blind Person’s Allowance - Annual Income/ Dividends
- Bonuses, Tips, Commissions - Net Business Income - Guaranteed Income Supplement
- Foreign Income from any source - Gross Rental Income - Interest/ Profit Sharing
- Pension, Old Age Security - Support Payments/ Alimony - Research Grants
- War Disability, Vets Allowance - GAIN/Welfare Payments - EI Benefits
I HEREBY ACKNOWLEDGE THAT MY SIGNATURE ON THIS APPLICATION WILL BE
CONSIDERED AS AUTHORIZATION TO MAKE NECESSARY FINANCIAL INQUIRIES.
Applicant's Signature: ______________________________ Date: _________________________
Other Adult's Signature: ____________________________ Date: _________________________
Page 5 of 5
