Applications Sheltered Housing

Sheltered Housing

Personal Information

Title: *

Surname: *

Forename(s): *

Date of Birth: *

National Insurance No: *

Title:

Surname:

Forename(s):

Date of Birth:

National Insurance No:

Address: *

Postcode: *

Telephone: *

Relation to first applicant:

Email: *

Name of Local Authority: *

Where do you live: *

(flat, house, maisonette, bungalow, bed-sit, hotel, hostel, L.A. temp. accommodation)

Accommodation Terms: *

Is your current accommodation sheltered?: *

Are you currently homeless: *

Are you staying with?: *

Do you have use of the following facilities? (Please select as appropriate)

Bedroom: *

Living room: *

Kitchen: *

Bathroom: *

Internal WC: *

Hot Water: *

Central Heating: *

Lift: *

What are your reasons for making this application?: *

Are you registered disabled?: *

Please explain the nature of your disability: *

Do you need any special adaptations made to your home?: *

Your physical capability, please select the most appropriate

Manage your home, cleaning shopping cooking etc?: *

Manage yourself, bathing etc?: *

Mobility both inside and outside of your home?: *

Manage your finances and day to day paperwork?: *

Do you own a car?: *

Do you own a pet?: *


Have you or anyone on your application had any criminal convictions: *

Do you or anyone on your application have a probation officer: *

If you have answered yes to either of the above questions please give brief details:


Are you or in the case of joint applicants:

Related to anyone employed by JCHA: *

Related to a Committee Member of JCHA: *

Are there any further details that you would like to give in support of your application for housing?: *

Please make a choice based on areas listed

1st Option: *

2nd Option: *

3rd Option: *

4th Option: *

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