Salvation Army Housing Association Housing Application
For help in completing this form, please contact the Customer Services Centre (Tel:
0800 970 6363)
Customer Services Centre Address:
33-35 Chorley New Road, Bolton, BL1
for:______________
4QR Telephone: 0800 970 6363
Fax: 01204 375768
Scheme/Project applying
______________________________________
Please complete all the questions. We will not be able to process you application
otherwise.
PERSONAL DETAILS
Applicants name (Mr, Mrs, Miss, Ms) __________________________________________________
Address _________________________________________________________________________
__________________________________________________ Postcode _____________________
Telephone number (daytime) __________________________ (evening) ____________________
(mobile) _____________________ email address ________________________
Next of kin _________________________________________Telephone number ______________
Contact address if different from above
________________________________________________
National Insurance number _________________________________________________________
Are you related to an employee/member of the Salvation Army Housing Association?
If yes, who? _____________________________________________________________________
Have you ever been cautioned or convicted of a criminal offence? Yes No
If yes, please give details of all offences and
dates_______________________________________
Has the conviction been spent? Yes No
Please give details of any current probation or other kind of community order. Include
any current or previous bail
conditions___________________________________________________________
YOUR HOUSING NEEDS
TYPE
WHO
OF ACCOMMODATION APPLYING FOR
Elderly 60+
Single Person/Couple
Family
Accommodation With Support
Foyer
Supported Scheme
NEEDS TO BE REHOUSED?
Please give details of everyone who needs to be re-housed, starting with yourself:
SURNAME
FIRST
NAME
MALE
OR
FEMALE
AGE
DATE
BIRTH
OF
REGISTERED
RELATIONSHIP
DISABLED
TO YOU
Applicant
DO
THEY
LIVE WITH
YOU?
Are you, or any of the people to be rehoused with you, expecting a baby? Yes No
If yes, who is expecting and when is the baby due?
______________________________________
(Please attach proof of pregnancy, ie, copy of certification or confinement.)
Do you, or anyone moving with you:
Have difficulty climbing stairs
Need ground floor
accommodation
Use a wheelchair in the house
Require special adaptations
If yes, please give details
WHERE
DO YOU LIVE AT THE MOMENT?
Local Authority accommodation
Housing Association/Registered
Social Landlord
Private Tenant
Hostel/shared supported housing
Owning or buying
Living with friends/family
Self-contained supported housing
tenant
Approved probation/bail hostel
DETAILS
Childrens home/foster care
Hospital
Prison
Residential care home
Bed and breakfast
Squatting
Sheltered accommodation
No fixed abode
Other
____________________________
OF YOUR PRESENT HOME
How many bedrooms does your present home have? _______
DO
YOU HAVE (TICK ONE BOX ONLY):
YES
NO
SHARED
IF SHARED, WHO WITH
Use of a bath or shower
An inside toilet
A separate bedroom
A separate kitchen
Central heating or storage
heaters
A hot water supply
PROPERTY
CONDITION
Does your home have any of the following:
Leaking roof
WHO
Dangerous electrical wiring
Severe damp
Rain water penetrating property
Other, please describe
_____________
ELSE CURRENTLY LIVES WITH YOU WHO IS NOT MOVING WITH YOU?
SURNAME
FIRST
NAME
MALE
OR
FEMALE
AGE
DATE
BIRTH
OF
REGISTERED
RELATIONSHIP
DISABLED
TO YOU
DO
THEY
HAVE THEIR
OWN ROOM?
WHY DO YOU WANT TO MOVE?
To be rehoused from short-stay
hostel
To get away from other
harassment
To be rehoused from an
institution
To get away from domestic
violence
To move-on to supported selfcontained housing
I have problems relating to
physical health
To receive higher support
I am a refugee/asylum seeker
I have been asked to leave home
I am on a probation service order
I am a rough sleeper
Other
______________________________
HOW
I need specially adapted
accommodation
To leaving home of family or
friends by choice
To get away from racial
harassment
To get help with alcohol/drug
rehabilitation
I have been evicted from my
housing
WOULD YOU DESCRIBE YOUR CURRENT ECONOMIC STATUS?
Working full-time
Working part-time
Training full-time
Training part-time
Voluntary Work
Foster Parent
Full-time carer
Unemployed
Retired
Student
Sick
Higher Education
Further Education
Job Seeker Allowance
Incapacity Benefit
Income Support
Disability/ DLA
Prefer not to say
Other (please
state)______________
Home not seeking work
Are you in receipt of any welfare benefits?
If yes, which ones_________________________________________________________________
If no, what is your weekly income? __________________________________________________
Do you have any debts or outstanding housing arrears? (Please give details)
_________________
If you must leave your present address, what date must you leave by?
_____________________
DO
YOU QUALIFY FOR ANY OF THE FOLLOWING?
Housing Benefit
Residential Allowance
Neither HB or Residential
Allowance
If you are a tenant in your current
property, please provide the Landlords
name, address and telephone number:
________________________________________
________________________________________
________________________________________
________________________________________
_________________________
If you are the owner, or part-owner of
this property:
How much is the property worth?
______________________________
How much of your mortgage is left to
pay? ______________________________
Number of years left on your mortgage
____
(Your building society or lender will tell
you.)
Is the property currently for sale?
Yes No
Dont know
Do you, or anyone to be rehoused with you, own any other properties? Yes No
Have you sold any properties within the last 5 years?
If yes: Address of sold property ______________________________________________________
Date of sale _________ Sale price ___________ Amount of equity/capital gained
______
Do you, or anyone being rehoused with you, keep any pets? Yes No
If yes, please say what type of pet you have and how many?
______________________________
Have you applied to the Salvation Army Housing Association in the past? Yes No
If yes, when? ____________________________________________________________________
Are you on a Councils waiting list? Yes No
If yes, which one? ________________________________________________________________
Are you any other Housing Associations waiting list? Yes No
If yes, which one? ________________________________________________________________
REFERENCES
Please give details of your addresses over the last 10 years. If you have not held a
tenancy previously, please give details of two persons who could provide a personal
character reference.
From
To
Reason for leaving
Others
You
Previous address
Name & Address of Referee
Relationship to
applicant
Date known since
ADDITIONAL INFORMATION
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Statement
Please read this declaration and sign below.
I understand that the Association will decide whether to allocate a tenancy/licence agreement
based on the information on this form. The information I have given is true and complete to the
best of my knowledge. I will tell the Association if my circumstances change. The Association
reserves the right to apply to the courts to take back any tenancy/licence agreement that is
given based on false information.
It is the Associations policy to grant joint tenancies wherever applicable for general
needs accommodation. All applicants who wish to be included on the tenancy/licence
agreement and are over the age of 16 must sign below.
Signed _______________________________________________
Date _____________________
Signed _______________________________________________
Date _____________________
Information supplied on this form may be put on our computer and used as part of our
allocations policy. We will treat the information you give us as confidential and will only use it
to assess your housing needs. Before returning this form, please make sure ALL questions
are answered fully. Please return the completed form to address on the front of the form.
EQUAL OPPORTUNITIES MONITORING FORM
The Association operates policies designed to ensure that all applicants receive equal
treatment, regardless of their ethnic origin, sex or physical disability. To enable the
Association to monitor whether its policy is fully carried out, will you please provide
the following information. This information will NOT affect your application, and if you
would prefer not to answer the questions, this view will be respected.
FIRST APPLICANT
How would you describe your ethnic origin?
White British
White Irish
White other
Mixed: white & black Caribbean
Mixed: white & black African
Mixed: white & Asian
Mixed: other
Asian/Asian British: Indian
Do you consider yourself to have a
disability? Yes No
Do you use a wheelchair?
Asian/Asian British: Pakistani
Asian/Asian British: Bangladeshi
Asian/Asian British: other
Black/black British: Caribbean
Black/black British: African
Black/black British: other
Chinese
Other
Sikhism
Yes No
What is your religion?
Christianity
Hinduism
Islam
Judaism
Buddhism
No religious beliefs
Prefer not to say
Other (please
state)__________________
Are you: Male
Female
SECOND APPLICANT
How would you describe your ethnic origin?
White British
White Irish
White other
Mixed: white & black Caribbean
Mixed: white & black African
Mixed: white & Asian
Mixed: other
Asian/Asian British: Indian
Asian/Asian British: Pakistani
Asian/Asian British: Bangladeshi
Asian/Asian British: other
Black/black British: Caribbean
Black/black British: African
Black/black British: other
Chinese
Other
Do you consider yourself to have a
disability? Yes No
Do you use a wheelchair?
Yes No
What is your religion?
Buddhism
Christianity
No religious beliefs
Hinduism
Prefer not to say
Islam
Other (please
Judaism
state)__________________
Sikhism
Are you: Male
Female
