Test - Kehilla Montréal

Identification

First name*

Last name*

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Primary phone*

Email*

Information on current living situation

Number of persons in the dwelling*

Number of adult(s)*

Number of children (under 18)*

Household composition

Name*

First Last

Relationship*

Gender*

Date of birth*

Name*

First Last

Relationship*

Gender*

Date of birth*

Name*

First Last

Relationship*

Gender*

Date of birth*

Name*

First Last

Relationship*

Gender*

Date of birth*

Name*

First Last

Relationship*

Gender*

Date of birth*

Name*

First Last

Relationship*

Gender*

Date of birth*

Name*

First Last

Relationship*

Gender*

Date of birth*

Name*

First Last

Relationship*

Gender*

Date of birth*

Name*

First Last

Relationship*

Gender*

Date of birth*

Name*

First Last

Relationship*

Gender*

Date of birth*

Current rent*

Current dwelling size*

Amenities included in current lease*

electricity
heating
hot water
parking
refridgerator/stove
none
other

Other*

Source(s) of revenue (check all that apply)*

Employment
Pension
Federal child benefit and provincial family allowance
Old age security
Guaranteed income supplement
Provincial disability pension
QPP retirement pension
Other

Other*

Occupation (if applicable)*

Occupation of partner or spouse (if applicable)*

Employer Information

Company name*

Contact person*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone*

Date of hire*

Hidden

Total household revenue (all persons 18+)*

Required apartment size

How many people will live in the apartment*

Please enter a number from 1 to 9.

Number of adults*

Please enter a number from 1 to 9.

Number of children (under 18 years)*

Please enter a number from 0 to 8.

Do you require a dwelling that is adapted for a handicapped person?*

Yes
No

Is there a person older than 65 years?*

Yes
No

Which borough are you looking for?*

Do you require services from Ometz Agency or Cummings Center?*

Yes
No

By selecting this box I attest that all the information provided and contained herein is true and accurate.*

Confirm

By submitting this form, you are not submitting an application, but simply a declaration of interest in housing. Please note that all information collected here will be kept confidential. If there is a need for further information, we may contact you at a later time.

Name

This field is for validation purposes and should be left unchanged.

Inquiries-English

Identification

Information on current living situation

Household composition

Employer Information

Required apartment size