FOR OFFICE USE ONLY
Please complete this form as fully as possible, if incomplete it will be returned to you. Contact HomeChoice if you need help completing this form.Title / Given Name (s) / Surname / NI Number / D.O.B / M/F
Applicant1 / Address
Postcode: / Applicant2 / Address
E-Mail Address / Do you want to be added
to the advert e-mailing list? / Y / N
Telephone No / Home: ______Work: ______Mobile: ______
HOUSEHOLD DETAILS Please give details of all people who will be living with you
FULL NAMES / RELATIONSHIP / DOB / M/F
ETHNIC ORIGIN Please identify your household’s ethnic origin – tick one box. This information is confidential and is used to check that our equal opportunities policy is working fairly.
White: British / White: Irish / White: Other
Mixed: White & Black Caribbean / Mixed: White & Black African / Mixed: White & Asian
Mixed: Other / Asian/Asian British: Other / Asian/Asian British: Pakistan
Asian/Asian British: Bangladeshi / Black/Black British: Other / Chinese/Other: Chinese
Black/Black British: African / Refused
PRESENT ACCOMMODATION Please tick relevant box and give additional info where required.
Owner Occupier / Renting / Other
Current Landlord’s Name, Address & Telephone Number
PLEASE COMPLETE IN FULL YOUR ADDRESSES FOR THE LAST 5 YEARS
Date From / Date To / Property Address Landlord Name and Address
And Telephone number
HAVE YOU REGISTERED WITH YOUR LOCAL AUTHORITY? / NO / YES
If Yes - Which Council
HOUSING REQUIREMENTS – please give details of any disabilities that may effect your housing need
WHAT IS YOUR REASON FOR WANTING TO MOVE? – Please give brief details
DO YOU HAVE ANY PETS? / YES NO
DECLARATIONPlease tick one box for each question YES NO
Have (either of) you been served a Notice to leave your home or
been evicted from a property?
Do (either of) you have any rent arrears? Have (either of) you been served any notice concerned with
Do (either of) you have any criminal convictions other that those
Spent under the 1974 Rehabilitation of Offenders Act.
Are you a member of the Association’s staff or Board of Management,
or are you related to someone that is?
If you have ticked YES to any of the above questions, please give details below:
PLEASE READ THE FOLLOWING CAREFULLY – in signing this form you agree to the following:
- I/We certify that all the details given on this form are correct and complete and I/We will inform LHA of any changes in circumstances
- I/We understand that this application is for the use of the LHA only and does not bind LHA to make any offer of accommodation or the applicant to accept any offer made.
- I/We understand that LHA has the right to cancel my/our application, or to take action to repossess any property I/We obtain by deliberately giving false information.
AUTHORITY TO ACCESS PERSONAL DATAI/We, the undersigned, give my/our explicit consent for any information relevant to my/our waiting list/tenancy with LHA to be disclosed by the aforementioned landlords to the following third parties and for any such relevant information to be disclosed to LHA by those third parties, namely:
The Police, Social Services, Probation Service, Local Authorities, other Registered Social Landlords and other corporate agencies or persons processing my personal data. I/we understand that all personal data will be handled strictly in accordance with the Data Protection Act 1996.
SIGNED / DATED
To ensure that your application form is processed as quickly as possible please enclose a reference from your current (or most recent) landlord when you return this form to us.
The reference will need to show that you have: (a) a clear rent account, or a repayment plan which you have kept to and (b) that you have conducted your tenancy in a satisfactorymanner.
If you cannot provide a reference – please state below your reasons clearly and your circumstances will be considered.
PLEASE BE AWARE THAT IF YOU FAIL TO ATTACH A REFERENCE (OR TO GIVE A VALID REASON FOR NOT ENCLOSING ONE) WE MAY REJECT YOUR APPLICATION
Please return COMPLETED to: HomeChoice, LHA, 174 Derby Road, Nottingham, NG7 1NF.
Tel: 0115 9709600 / Fax: 0115 9701071 /