FORM APPLICATION. Your application In whichcourt/area /towndoyou wishtolive?

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1 APPLICATION FORM All applicants should complete the form in BLOCKCAPITALS and as fully as possible.(*mandatory) Allinformation given on thisform is treated in strict confidence. Your application In whichcourt/area /towndoyou wishtolive? Type of property (please tick): Studio One bedroom Two bedroom Floor level (please tick): Don t mind Higher floor Ground floor Don t No stairs mind If the area or courtofyour choicehas along waiting list would you be happy to be offered other suitable vacancies? Do you have any pets? If,what type of pet? Please confirm you are able to move within six months. Applications will only be accepted if that is the case. If please re-apply when you are ready to move What areyour reasonsfor seeking a move? Personal details* Please give the following details for you and your household: Title Surname First Name(s) SexM/F Date ofbirth Relationship to you, the applicant Present address: Postcode: National Insurance number Applicant: Partner: address: Telephone (home): Mobile: In what year did you move into your current address?

2 Are you an existing resident of Housing & Care 21? If so, what is your rent account number? Are you, or have you previously been, employed by Housing & Care 21? If, in what capacity and when? Do you work? (please circle) Which local authority area do you live in? Current tenure: Owner / occupier Lodging Local authority tenant Private landlord renting Other (please specify) Retired Full time Part time Seeking If you have lived in your current home for less than five years please give all previous addresses for those five years * (may be contacted for references to support your application): Address Dates from to Landlord s name, address and phone number If you are renting, please give the name and full postal address of your landlord * (may be contacted for a reference in support of your application): Name: Address: Post Code: Tel. No: Details of health, care and adaptations to housing required Please give details of any health or mobility problems (please also list any aids and adaptations you have or state if you need them in your new home as determined by your GP or Occupational Therapist). Applicant Partner/other(s) Please give details of any care or support packages presently received, for example meals on wheels, home care etc. Please provide a copy of this if possible to help us when assessing your needs. Applicant Partner/other(s) Are you at risk of homelessness or threat of it, domestic violence or serious harassment, severe health problems directly affected by your current housing/location? Please give details. Additional priority can be given subject to evidence. Applicant Partner/other(s)

3 Would you like further details of the other services provided by Housing & Care 21, for example care provision, domestic services? Do you need any help or advice on claiming benefits? Do you and everyone to be housed with you have the right of residence in the UK? Are youoranyone to be housed with yourelated to ahousing &Care21staff member or Board member? Do you own or have atenancy at anyother property? Do you owe rent arrears to acurrent or former landlord, or mortgage arrears? Haveyou or anyone in your household been evicted from aproperty or been subject to possession proceedings within the last 2years? Haveyou or anyone in your household forfeited aprobationary/introductory/ starter tenancy in the last2years? Haveyou or anyone in your household been served with an Anti-socialBehaviour Order (ASBO) or Acceptable Behaviour Contract (ABC) in the last2years? Haveyou or anyone in your household received anotice toquit or anotice of SeekingPossession in the last2years? Do you have any convictionsfor acriminal offence other than aspent conviction under the Rehabilitation of Offenders Act 1974? If so,please give details of the offence, date of conviction and sentence: Do you have aprobation worker? Do you need anyother help to manage atenancy or to live independently? Do you have aperson(s) acting onyour behalf as Power ofattorney? If so,please give details and contact number: Are you aprevious resident of Housing &Care 21?

4 Our marketing Where did you hear about Housing &Care 21 (please give details) Newspaper Localshop advert Poster Magazine Promotional material Other - further details Elderly Accommodation Counsel website Localauthority Housing &Care 21 website RoyalBritish Legion Friend /word ofmouth Declaration The Association ensures that where a tenancy is offered to Board or committee members, members or staff of the Association or their close relatives, that there is favouritism. If you are a member/related to any member or officer of the Association, please give details below: Under the Data Protection Act we must tell you what we will use your personal details and sensitive data for and we must store it safely. The information you have given will be used to allow us to assess and prioritise your application for housing and correspond with you. On occasion we are required to supply statistics to organisations that regulate us. We will t divulge any information we hold about you unless you agree, we are required to do so by law or we have to do so in order to protect our rights. I /we confirm that the information I /we have supplied is accurate and may be held by Housing & Care 21 in accordance with the particulars above. I /we understand that the completion of this form does t imply that I /we will automatically be entitled to an offer of accommodation. By ticking this box you give consent for a Housing & Care 21 representative to contact relevant agencies, organisations or previous landlords in order to obtain further supporting information relating to your application for housing. We reserve the right to request references at a later date. We reserve the right t to house you should you give false information. *Date: Thank you for completing this form. Please save a copy and it to: The Lettings Team at lettings@housingandcare21.co.uk Or print a copy and post it to, Housing & Care 21, 10th floor, Tricorn House, Hagley Rd, Birmingham B16 8TP Housing & Care 21 is an exempt charity

5 Equal opportunities We monitor these categoriesto ensure thateveryone who appliesfor accommodation is treated equally and fairly and that our policies and procedures comply with legislation. If you do t want to answer these questions it will t affect your application and will t be used for selection purposes. How do you describe your ethnic origin? White British White Irish White Other Mixed White&Black Caribbean Mixed White&Black African Mixed White&Asian Mixed Other AsiarAsian British Indian AsiarAsian British Pakistani AsiarAsian British Bangladeshi AsiarAsian British other Black or Black British African Black or Black British other Chinese or other ethnic group Chinese Other ethnic group Gypsy, Romany,Traveller Other ethnic group Arab Prefer t to answer What is your religion? Buddhist Christian(includesChurch of England, Catholic, Protestant and allother Christiandeminations) Hindu Jewish Muslim Sikh None Anyother,pleasestate Prefer t to answer Do you consider yourself to have adisability? What of the following best describesyou? Heterosexual Gay/Lesbian Bi-sexual Prefer t to answer Foroffice use only Please do t complete any sections in this box Referencenumber LA Nom Sheltered Date application received Transfer Dateapplication archived

6 If you have any questions about this form please contact our Lettings Team: Housing&Care21 Tricorn House Hagley Road Edgbaston Birmingham B16 8TP If you need this document in a different format,for example large print,braille or ather language, please contact the Lettings Department on