Sheltered housing applications

Personal Information

Person 1

Title Forename(s) Surname

Date of Birth:(Required)

National Insurance No: *(Required)

Person 2

Title Forename(s) Surname

Date of Birth:

National Insurance No: *

Address(Required)

Street Address Address Line 2 City Postcode Country

Phone(Required)

Email(Required)

Relation to first applicant:

Name of Local Authority(Required)

Where do you live

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

Accommodation Terms(Required)

Is your current accommodation sheltered?(Required)

Are you currently homeless?(Required)

Are you staying with?(Required)

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?(Required)

Are you registered disabled(Required)

Please explain the nature of your disability(Required)

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?(Required)

Manage yourself, bathing etc?(Required)

Mobility both inside and outside of your home?(Required)

Manage your finances and day to day paperwork?(Required)

Do you own a car?(Required)

Do you own a pet?(Required)

Have you or anyone on your application had any criminal convictions?(Required)

Do you or anyone on your application have a probation officer?(Required)

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?(Required)

Related to a Committee Member of JCHA?(Required)

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

Where did you hear about jLiving?

Please make a choice based on areas listed

1st Option(Required)

2nd Option(Required)

1st Option(Required)

3rd Option(Required)

4th Option(Required)

To Allow the Association to monitor our Equal Opportunity Policy, please complete the questions below.

The Association wants to treat all applicants equally, whatever their race, colour or ethnic origin.

Ethnic Origin(Required)

Religion(Required)

Other

CAPTCHA