Housing Application Form

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1 Housing Application Form Office Use Only Date Received Application Number Post Other Referral Source IR NI ID Ref: r w READ CAREFULLY BEFORE FILLING THIS APPLICATION FORM Causeway Irish Housing Association currently provides Short life Shared Housing only. Causeway Short life Shared Housing scheme offers unfurnished rooms in shared houses. Applications submitted without housing reference from previous/current landlord, photographic ID and proof of income will not be assessed. Incomplete applications will be rejected. Further information can be found on our website Office Use Only Interview Date: Time: Accepted Rejected NS Offer Address: Viewing Date: Time: Full Name Current Address (Residential Address including postcode) Telephone (we will text you with the outcome of your application) Date of Birth Age Post Code Address National Insurance No: Male Female 1

2 Next of Kin (Emergency Family Contact) Name Relation to you: Address (Eg. father, mother, sister, brother) Phone number: Postcode Do you have literacy or language issues? Yes No Do you have children? Yes No Employment and Benefits Are you in employment? Yes No What is the nature of your employment? How much do you get paid after tax and national insurance? Per Please provide a copy of your most recent payslip Are you getting any benefits or waiting to hear about benefits you have claimed? Yes No Name of the benefit?(please provide a copy of your award letter) What is your nationality? Are you Irish: Birth Descent N/A What is your current housing situation? Please describe where you are living at the moment (e.g. hostel, family home, etc. Do not write homeless ) Have you got a mental health problem? Yes No Previously Have you got a problem with the misuse of drugs? Yes No Previously Have you got a problem with the misuse of alcohol? Yes No Previously Have you got any other health problems? Yes No Previously If yes you must provide further information Do you have a Support Worker, Social Worker, Yes No Mental Health Key Worker? If yes please give details Name Number 2

3 Housing History Please give a description of your housing history for the past 5 years. Start with your most recent address and include dates and locations. Address (including postcode) From (Date) Month Year To (Date) Month Year Were you the owner, the tenant, living with friends, homeless or hostel? Why did you leave this address? Example 1 Mangrove Road London, N17 1AB Mar 2009 Feb 2012 Private Tenant Tenancy ended Do you have any experience of living in a shared house? Yes No Do you have any criminal convictions? Yes No If yes, please provide more details. You must provide a list offences and a probation report. Have you ever applied to Causeway or held a tenancy with Causeway before? Yes No It may help us to place you if you tell us of any current or former Causeway tenants that you know? 3

4 Check List Failure to supply the following documents will result in your application not being processed. Reference Please attach a housing reference. This reference must be from your previous or current landlord / housing provider. ID One form of proof or your identity e.g. Birth Certificate, Passport, Residence Permit, Marriage certificate, Driving Licence. Proof of income Most recent payslip or benefit award letter. Probation Report / OLASS if applicable Declaration I understand that if I have given false information or deliberately left out important information, my application and any future tenancy may be revoked. I give Causeway Irish Housing Association permission to obtain information from third parties in order to access my application. Signed Date Filling This Form for Someone Else Please tell us why you are filling this form for someone else. As far as possible, I have confirmed with the person applying that the answers I have written on this form are correct. Name of person who filled in this form Signature of person who filled in this form Relationship to the person applying Date 4

5 Housing Area Preference Please tick all areas that you may be interested in living. Please bear in mind that an offer will be made in one of the areas of your selection. Haringey Islington Hackney Tower Hamlets Hammersmith And Fulham Return form Post Haringey Irish Community Centre Third Floor, Causeway Housing Assn. Pretoria Road London, N17 8DX Phone

6 Equal Opportunities Causeway Irish Housing Association is committed to fair and equitable treatment for applicants. The information on this form is not part of the housing selection process and does not affect your application in anyway. You do not have to answer any of the questions in this section. Describe your ethnic origin What is your sexual orientation? Bisexual Heterosexual Gay Lesbian Undecided Disability The Disability Discrimination Act defines disability as someone who has a substantial impairment that has a long-term (a year minimum) adverse effects on day-to -day activities. Do you consider yourself to have a disability? Yes No Are you registered disabled? Yes No Thank you for taking the time to complete the form. 6

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