Have you ever had a concussion, or hit to the head causing confusion, headache and memory problems? 11. Do you have any problems with your eyes or vision?
Have you ever been convicted of a crime (other than traffic infractions)? Yes □ No □ (If yes, give details: ) Acknowledgment and authorization:
1. Fair Housing: This community does not discriminate on the basis of race, color, religion, national origin, sex, handicap or familial status.
2. Identity: All applicants, co-applicants and co-signors/guarantors must present government issued photo identification at time of application.
Have you ever been convicted or found guilty by a Court of any offence in any country (excluding parking but including all motoring offences even where a spot fine has been administered by the police) or have you ever been put on probation or absolutely/conditionally discharged or bound over after being charged with any offence or is there any action pending against you? You need not declare convictions which are “spent” under the Rehabilitation of Offenders Act (1974). Yes/No* (If yes please give details here)
Have you ever had a license (other than a driver's license) revoked or suspended? Yes No
Have you ever been convicted of a felony? This includes pleading no contest or guilty to a felony.
Have you ever been expelled, dismissed, or suspended from a post- secondary institution for a non-academic reason?
Have you ever been convicted of a crime (other than traffic infractions)? Yes □ No □
Have you ever been the subject of a civil lawsuit involving, or an investigation or allegation of,
Have you ever a. Received treatment, advice or counseling from a physician, other practitioner or an organization for an alcohol problem? [_] [_]
b. Used cocaine or other drugs except as prescribed by a physician or licensed practitioner? [_] [_]
Have you ever been the subject of a civil lawsuit involving, or an investigation or allegation of, sexual misconduct, sexual harassment, or other immoral behavior or conduct, involving adults or children? If yes, please describe the circumstances and provide the name and address of the employer, educational institution, church, or other organization where the lawsuit, investigation, or allegation arose or occurred.
