FOR OFFICE USE ONLY

Reg date

  

Reg No

  

Input by

  

Ack sent

  

Tran ACK

  

Please print this form off and send it to the address shown at the bottom.

Registration Form

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

            

Applicant2

            

 

 

Applicant 1 Address:

Applicant 2 Address:
   

Email Address:

Do you wish to be on our mailing list?: Y / N

Telephone
 Numbers

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 Telephone Number
     
     
     
     
     
     
 
HAVE YOU REGISTERED WITH YOUR LOCAL AUTHORITY?
NO
YES
If Yes - Which Council
  

Registration Number

  

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                  

DECLARATION - PLEASE ANSWER EACH QUESTION

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 anti-social behaviour?

Do (either of) you have and cruminal convictions other than those spent under the 1974 Rehabilitation of Offenders Act?

Are you a member of the Associations staff or Board of Management or related to someone who is?

If you have chosen Yes to any of these questions please give details below:

 

 

 

 

 

 

Yes / No

Yes / No

Yes / No

 

Yes / No

Yes / No

 

Yes / No

 

 

 

 

 

PLEASE READ THE FOLLOWING CAREFULLY – in signing this form you agree to the following:

1.      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

2.      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.

3.      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 DATA

I/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.

AUTHORISATION

 

SIGNED

DATED

APPLICANT 1

    

APPLICANT 2

    

 

REFERENCE

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 satisfactory manner.

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 / www.homechoice.org.uk