AMS

Golden Cockroach Award Nomination Form

Note: Your name and contact information is for verification purposes only.

Section A: "Rate your house"

Do you have a problem with any of the following?

If so, please rate the problem from 1 to 5; 1 being a minor problem and 5 being a serious problem.

Problem Level	1	2	3	4	5
Mould or Mildew
Missing or broken screens on windows
Broken windows
Missing handrails on steps
Inoperable windows or poor ventilation
Cracked or slanty floors or walls
Peeling paint
Rodents or vermin
Draughty/Drafty windows or doors
Broken appliances
Insufficient hot water
Other, please describe below

Section B: "Rate your landlord"

Have you ever asked your landlord to fix any of the above problems?

Yes

No

If yes, how long did it take for the problem to be resolved? 1 being never resolved, 5 being quickly resolved?
	1	2	3	4	5

On a scale of 1 to 5, 1 being horrible and 5 being wonderful, please rate your relationship with your landlord.
	1	2	3	4	5

Comments

Anything else you would like to add?

If you wish to submit pictures, they can be e-mailed to mac@ams.queensu.ca

Please limit message size to 5MB.