Registration Form Office use only: Band: Date: Your Details Applicant 1 Applicant 2 Title (eg. Ms, Mrs, Mr) First Name(s)

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1 Office use only: Registration Form Band: Date: Your Details Applicant 1 Applicant 2 Title (eg. Ms, Mrs, Mr) First Name(s) Surname [Any former names] Date of Birth date month year date month year Gender (please tick one) Male: Female: Trans: Male: Female: Trans: Your Current Address: Applicant 1 Applicant 2 *(if no fixed abode, an address MUST be given for application purposes) Postcode Can we contact you at this address? Telephone number (home) (mobile) address National insurance number * This must be provided Contact Address: Applicant 1 Applicant 2 (if you do not want letters sent to your home address) Postcode Find your new home with

2 Are you pregnant? What date is your baby due? * We require proof of pregnancy eg. Maternity book / scan Please list your previous addresses for the past 4 years Address Date from Date to Name & address of Landlord Was this a Pennine tenancy? (tick) Applicant 1 - Employment details Employed Full Time (name & address of employer) Employed Part Time (name & address of employer) Unemployed Full time student Long term sick Retired Other (please state) Applicant 2 - Employment details Employed Full Time (name & address of employer) Employed Part Time (name & address of employer) Unemployed Full time student Long term sick Retired Other (please state) Are you a member of Her Majesty s Armed Services? What is your due date for Discharge? 2

3 Current housing and your housing needs About your household - Please list all people living at your current address. Title First name Surname Male/ female Date of birth Relationship to you (App 1) Moving with you / Please tick the type of property that you currently live in. Bungalow House High rise flat (floor number) Maisonette Low rise flat (floor number) In your current home are you? Living with friends or family Home owner Renting privately Council temporary accommodation (eg.hostel) fixed abode / homeless Renting from a Council Renting from Pennine Housing 2000 Living in Supported Housing Renting from a Housing Association In prison What is the name & address of your current landlord? Name Address Telephone What date did your tenancy start? 3

4 How many bedrooms does the property you currently live in have? Please tell us the names of who currently sleeps in each room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Other room Please tick any facilities which you share with people other than your family members. Living room Bathroom Kitchen Toilet (w/c) If you are a current tenant of a Housing Association, including Pennine Housing 2000 living in the Calderdale area and would like to join the mutual exchange register (to swap homes with another tenant) please apply online at Have you received any of the following Orders? (please tick all that apply) Closing Order Prohibition Order Category 1 Hazard tice from any Local Authority Do you or anyone on your application receive any of the following support? (please tick all that apply) Social Worker Community Psychiatric Nurse Occupational Therapist Probation worker Support Worker Other If yes, please provide their name and contact details below:- Name Agency Telephone Medical & welfare grounds for rehousing (please tick the boxes which apply) Are you interested in sheltered housing accommodation? (for people over 50 years old) Are you interested in extra care accommodation? (Specially designed to meet the needs of older people who are frail and less able to manage - over 60 with a care need) Mytholm Meadows, Hebden Bridge Clement Court, Halifax Willow Court, Elland Does anyone in your household have mobility problems, getting in or around your home? Does anyone in your household have a disability? 4 Does anyone in your household use a wheelchair? Please tick your preferred choice below.

5 Does anyone in your household have problems with any of the following? Their speech Learning disabilities Other (name) App1 (tick) App2 (tick) Reading and writing Their sight Their hearing Poor Mental Health Do you receive Disability Living Allowance (DLA)? Low Medium High Do you receive mobility allowance? Do you receive attendance allowance? If anyone in your household has a medical problem/illness, how is it affected by where you live at the moment, please give details below? Please tick the access features you need in your new home. Ramp leading to property Wheelchair adapted bathroom Level/gentle sloping approach Wheelchair adapted kitchen Few steps (can manage one or two) Widened doors Walk in shower Do you have a guide or assistance dog? Stair lift External lift Do you need somewhere to store medical equipment. For example: A Dialysis machine? What are you struggling with in your current home? Stairs Access slopes Steps Bathing facilities Getting around Widened doors Other (Please state): 5

6 Domestic abuse. Please note that any information will be treated in the strictest of confidence and will only be forwarded to other agencies with your written consent. Are you suffering from domestic abuse? Do you wish to discuss the issue with a member of staff? If YES, a member of staff will contact you directly to arrange an appointment. They will not disclose what they are calling about to anyone other than yourself. What kind of property would you like to live in? Bungalow House High rise flat Maisonette Low rise flat Supported Housing (for people over 50 years old) Low rise flat (ground floor preferred) Extra Care (for people over 60 with a care need) How many bedrooms do you need? Have you ever had your own tenancy and/or owned your own home? Do you need help to manage a tenancy? (eg. paying bills, understanding your tenancy, claiming benefits etc.) Do you need help to bid /express an interest in a property? Please tell us if you have any pets. (Dogs or cats are not allowed in properties with a communal entrance). Dog Cat Other please state In which areas of Calderdale would you like to be rehoused? * Please note: The parishes of Blackshaw, Erringden, Heptonstall, Ripponden, Wadsworth, Hebden Bridge & Mytholmroyd require the Local Connection Section completing which can be found on pages 8 and 9. Are you interested in Shared Ownership? This scheme allows you to buy a share of a home and pay rent on the remainder and is particularly suitable for first time buyers. You need to be able to get a mortgage for this option. 6

7 Homelessness Do you believe you are at risk of becoming homeless? Have you ever contacted the Housing Options service for housing advice? Immigration If you answer YES to any of the below, please provide us with a copy of your passport and Home Office Papers. Are you, or any member of your family subject to any form of immigration control? What date did you enter the UK? Is your right to stay in this country limited by time? What date does your right to stay end? Why do you want to be rehoused and if applicable, why do you want to move to a particular area? * THIS SECTION MUST BE COMPLETED * Do you or your household have any criminal convictions? Name of offender Date of conviction Type of offence Relationship to interested parties Are you a member of Pennine staff or Pennine Board Member? Are you related to a member of Pennine staff or Board Member? If yes, please provide further details below. Name: Relationship: 7

8 How would you like us to contact you? Letter Telephone Mobile Phone Language other than English (please state below): Large Print Braille Audio Tape Please note: We may not always be able to contact you in your preferred format but we will wherever possible. Local Connection section * You only need to complete this section if you wish to move to any of the blue shaded areas on the map shown on the next page. If you are applying for housing in the following areas, please be aware that preference will be given to applicants who have a local connection with the area. This is because, in these areas, there are a number of factors (eg. high house prices, shortage of rented housing) which have made it difficult for people who need to live there to find suitable accommodation. Areas including:- Blackshaw Erringden Heptonstall Ripponden Wadsworth Hebden Bridge Mytholmroyd Applicants who do not have a local connection to these areas, will also be able to apply for housing and express an interest (ie. bid) for available homes in these areas, but preference will be given to applicants with a local connection. You have a local connection with an area if:- You have lived in the area for the previous 12 months You have lived in the area for a continuous period of 10 years You have permanent employment in the area You have immediate family in the area, who have lived there for the previous 5 years You need to live in the area to provide essential support to a permanent resident and there is no other person able to do this You need to move into the area to receive essential support from a permanent resident and there is no other way of receiving such support Please tick any which apply 8

9 If necessary, please give further details to support how you satisfy the local connection criteria:- A local connection is required for the parishes of Blackshaw, Erringden, Heptonstall, Ripponden, Wadsworth, Hebden Bridge and Mytholmroyd (shaded blue). Anyone can apply for housing in these areas however, preference will be given to those with a local connection. 9

10 Equal Opportunities Monitoring Form A. White / White British App1 App 2 British Irish Any other white background (please specify): B. Mixed App1 App 2 White & Black Caribbean White & Black African White & Asian Any other mixed background (please specify): F. Gypsies / Romany Travellers App1 App 2 Gypsies / Romany Travellers G. Any other EEA National Austria, Belgium, Cyprus, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Malta, Netherlands, Portugal, Spain, Sweden, Iceland, Liechtenstein, rway and Switzerland. Please specify below: App 1 App 2 C. Chinese / Other ethnic group App1 App 2 Chinese Any other ethnic background (please specify): D. Asian / Asian British App1 App 2 Indian Pakistani Bangladeshi Any other Asian background (please specify): E. Black / Black British App1 App 2 Caribbean African H. Religion App1 App 2 Buddhist Christian Hindu Jewish Muslim Rastafarian Sikh Do not wish to answer Other (please specify): I. Sexuality App1 App 2 Heterosexual Bisexual Gay man Gay woman (Lesbian) Do not wish to answer Any other black background (please specify): 10

11 DECLARATION Please read this declaration and then sign: I understand that: The information given on this form is, to the best of my knowledge, true and correct. I know I may lose my accommodation if I have given false information, or have deliberately withheld information. I/we must keep KeyChoice informed of any changes in our household, medical condition or housing situation. (This is very important as it could result in a change of your band or your eligibility for certain homes). KeyChoice may contact other agencies to verify information held on the form and will carry out a check for current and previous arrears and anti-social behaviour. I/we understand that details provided may be shared by KeyChoice for the prevention and detection of crime, including fraud and that it may be shared with other relevant bodies including the police to assess your suitability as a tenant. I/we authorise any landlord/agency named in this application form to provide information about me/us or any member of my/our household to KeyChoice, to make any enquiries necessary to support this application and to share this information with Calderdale Council and other Registered Social Landlords. Data Protection: The information you give us will be handled in accordance with the Data Protection Act Applicant s Signature Date Joint Applicant s Signature Date Thank you for completing this form. Please return your completed form to either of the addresses provided below. Doorways, The Square, Woolshops, Halifax, HX1 1RJ Pennine Housing 2000, Bull Green House, Bull Green, Halifax HX1 2EB (Head Office) or any Pennine Housing 2000 Office. Telephone our staff on: or at Doorways on your enquiries to: Keychoice@ph2k.org.uk * Important, please note; Your application will be returned to you if you have not supplied all of the information and evidence we have asked for. 11

12 Information the way you want it If you need this document translating or reproducing in Larger Print, Braille, on Audio Tape or by , please contact any Pennine Housing 2000 office. (Bengali) Informacja - w dowolnej formie (Polish) Jeśli chcą Państwo otrzymać ten dokument przetłumaczony lub wydrukowany większą czcionką, alfabetem Braille a, nagrany na kasetę lub przesłany pocztą elektroniczną proszę skontaktować się z jakimkolwiek biurem Pennine Housing (Urdu) Find your new home with

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