! 1 Alpha Homes Thursby House, 1 Thursby Road Croft Business Park Bromborough Wirral CH62 3PW 0151 346 1598 Ref No. --------------------------------- - Date Sent: -------------------------- Date Recv d: ----------------------- HOUSING APPLICATION FORM If English is not your first language please specify your first language: If you need: An Interpreter/Translation Service/Information in Braille/Large Text please contact us at the above address. MAIN PERSONAL DETAILS Title: First Name:. Surname: Have you ever been known by any other name?. Date of Birth: Gender: Male/Female National Insurance Number:.. Address: Post Code: Contact: Home: Work:. Mobile:. Email:.. SPOUSE/PARTNER DETAILS Relationship to the Main Applicant:.
2 Title: First Name:. Surname: Have you ever been known by any other name?. Date of Birth: Gender: M/F NI Number:.. SPOUSE/PARTNER DETAILS (continued) POUSE/PARTNER DETAILS Address: Post Code: Contact: Home: Work:. Mobile:. Email:.. YOUR CURRENT HOME When did you move into your present home? In your current home are you (Please circle): Housing Association Tenant Shared Ownership With/ Without Mortgage Tied Tenancy In Prison In Supported Accommodation Private Tenant Council Tenant Temporary Accommodation Armed Forces Accommodation Sheltered Housing Owner Occupier With/ Without Mortgage With Family or Friends In Hospital In a Hostel Other Previous address history
(If you have lived at your current address for less than three years please provide details of your addresses for the last five years. Continue on a separate sheet if necessary). 3............. WHAT ALPHA PROPERTIES ARE YOU INTERESTED IN? Alpha Court, Wallasey, CH45 8QR Ashley Court, Telford, TF4 3DA Barnfield, Dewsbury, WF13 2LS Brookes Court, Whitchurch, SY13 1GA Bedford Court, Rock Ferry, CH42 2EG Edel Quinn House, Upton, CH49 6PN Greenside House, Sheffield, S2 2ND Gerard Corr House, Wallasey, CH45 7QF Hesslewell Court, Heswall, CH60 7TW Homedee House, Chester, CH1 4HD Jessop Court, Little Sutton, CH66 3SR
4 Laurence Deacon Court, Birkenhead, CH41 3RS Manor House, Bromborough, CH62 7JN Naseby Court, Bury, M25 1LG Oaklands, Bromborough, CH62 6EL Red Dale, Heswall, CH60 7TA Regent Court, Newcastle-under-Lyme, ST5 8QZ Rocklands, Newcastle-under-Lyme, ST5 8RE Saxon Court, St Helens, WA10 2AT St Clements Court, Macclesfield, SK11 8DE St Columbas Close, Wallasey, CH44 8EY St Peter s Court, Leeds, LS11 5NR The Court, Bebington, CH63 3HX The Mount, Bebington, CH63 7PY Willow Court, Winsford, CW7 3HS Current landlord s name and contact details (We may wish to contact them for a reference) Name:.. Address:....
Post Code: Telephone: 5 Do you have any housing related arrears or debt? If YES, please give details:. NEXT OF KIN Name:.. Relationship: Address:... Contact: Home:.. Work:... Mobile:.. Email:.. PERSONAL CIRCUMSTANCES/SUPPORT Do you need any special aids, equipment, or mobility devices? If YES, please give details.. If you do not have a disability but suffer from a long term illness for which you receive regular medication or treatment, please provide full details..... Are you receiving any housing benefit? If YES, give details..
6 Are you receiving any other welfare benefits? If YES, give details.. Would you like to receive further assistance/information on welfare benefits you might be entitled to if you were offered an ALPHA property? ADDITIONAL INFORMATION Do you own a car? Do you own a mobility scooter? If you prefer to live on a particular floor please specify... (Please note that most of our accommodation has a lift and specifying one floor will limit your chance of being offered a flat). Why do you wish to move? Do you own any pets? If YES please describe what it is:.. Have you ever been in the armed forces? If YES, did you sustain any injury while serving in the armed forces? How did you hear about Alpha Homes?........
7 DID ANYONE HELP YOU TO COMPLETE THIS APPLICATION? If so, please give their full details, address and contact number....... Telephone Number: REHABILITATION OF OFFENDERS ACT 1974 Have you any criminal convictions or are there any pending? If YES, please give full details: Do you have a probation officer? If YES, please give full details. Do you have/have you ever had any drug or alcohol related issues? If YES, please give details and advise whether you are you currently receiving any support for this? Has any legal action ever been taken against you due to anti-social behaviour or harassment or nuisance? If YES, please give full details. CONSENT
8 Alpha Homes will use the information provided to us by third parties to help us make a decision about your application. We may also contact your current and previous landlords for a reference. By signing this form, you are consenting to allow us to contact third parties, including your current and previous landlords. I hereby confirm that the information provided by me is to the best of my knowledge true. I understand that if any of the information given is found to be untrue any tenancy entered in to may be terminated. Main Applicant Signature:. Date:. Full Name:.. Joint Applicant (If applicable) Signature: Date:. Full Name:..
9 SUPPORTING DOCUMENTS If your application is successful, at a later stage you will be asked to provide the documents specified below before an offer of accommodation is made. If you are on benefits please provide your benefits agency letter (Please note that this would act as proof of address), NI Number, and proof of ID. A reference from your current or last landlord If no previous landlord then please provide a character reference from your current or a previous employer. Proof of National Insurance Number Proof of identity in the following format will be accepted: Photo ID (eg. Passport, driving licence, bus pass or ID card. Proof of address in the form of a recent letter from your bank or building society, utility bill or council tax bill.
10 EQUAL OPPORTUNITIES Please circle as appropriate: A. White. D. Black, African, Caribbean, or Black British. 1. English, Scottish, Welsh, Northern Irish, British. 2. Irish 3. Other 12. Caribbean 13. African 14. Other B.Mixed E. Other Ethnic Group 4. White & Black Caribbean 5. White & Black African 6. White & Asian 7. Other 15. Gypsy, Irish Traveller 16. Chinese 17. Arab 18. Other C.Asian or Asian British F. Refused 8. Indian 9. Pakistani 10. Bangladeshi 11. Other 19. Refused Do you have a disability?
11 Under the Equality Act 2010, a person is considered to have a disability if he/she has a physical or mental impairment which has a substantial and long term effect on his/ her ability to carry out normal day to day activities. If YES, please provide full details of your disability:.... Please describe your sexuality:. say: Prefer not to