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Application for Accommodation in England and Wales

  1. Please ensure that you have all the information required before completing this form as must be completed in one go.

    You will need your NI Number, details of current and previous addresses, next of kin information, employment information and details of any Benefit Claims
  2. 1. Applicant’s Personal Details
  3. Title*
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  4. Your Full Name*
    Please type your full name.
  5. Date of Birth*

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  6. Place of Birth*
    Please enter a value for this field
  7. National Insurance Number*
    Please enter a value for this field
  8. Phone (daytime)*
    Please type your phone number.
  9. Mobile*
    Please type your phone number.
  10. Email*
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  11. Have you ever been known by any other name?*
    Please enter a value for this field
  12. If yes, please provide details and dates:
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  13. 2. Other persons whom will Be Residing At The Property (Please Include All Children)
  14. Extra Occupant 1 Title
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  15. Extra Occupant 1 Full Name
    Please type your full name.
  16. Extra Occupant 1 Date of Birth

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  17. Extra Occupant 1 Place of Birth
    Please type your full name.
  18. Extra Occupant 2 Title
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  19. Extra Occupant 2 Full Name
    Please type your full name.
  20. Extra Occupant 2 Date of Birth

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  21. Extra Occupant 2 Place of Birth
    Please type your full name.
  22. Extra Occupant 3 Title
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  23. Extra Occupant 3 Full Name
    Please type your full name.
  24. Extra Occupant 3 Date of Birth

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  25. Extra Occupant 3 Place of Birth
    Please type your full name.
  26. Extra Occupant 4 Title
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  27. Extra Occupant 4 Full Name
    Please type your full name.
  28. Extra Occupant 4 Date of Birth

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  29. Extra Occupant 4 Place of Birth
    Please type your full name.
  30. 2. Please supply your current and previous address
  31. Current Address*
    Please enter a value
  32. Postcode*
    Please enter a value
  33. Lived there from/to*
    Please enter a value
  34. Landlord's Name
    Please enter a value
  35. Landlords Tel. No
    Please type your full name.
  36. Landlord's Email
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  37. Previous Address
    Please type your full name.
  38. Postcode
    Please type your postcode
  39. Lived there from/to
    Please enter a value
  40. Landlord's Name
    Please enter a value
  41. Landlords Tel. No
    Please enter a value
  42. Landlord's Email
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  43. 4. Contacts
  44. Relationship*
    Please enter a value
  45. Their address*
    Please enter a value
  46. Postcode*
    Please enter a value
  47. Telephone Daytime*
    Please enter a value
  48. Telephone Evening*
    Please enter a value
  49. Doctor’s Name
    Please enter a value
  50. Doctor's Address
    Please enter a value
  51. Doctor's Postcode
    Please enter a value
  52. Doctors's Telephone
    Please enter a value
  53. Next of Kin: (or person to be contacted in the event of an emergency)*
    Please enter a value
  54. 5. Employment
  55. Name of employer: (or last employer)*
    Please enter a value
  56. Employer Address*
    Please enter a value
  57. Employer Postcode*
    Please enter a value
  58. Your job/title or description*
    Please enter a value
  59. Name of your work supervisor*
    Please enter a value
  60. Telephone No*
    Please enter a value
  61. Email*
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  62. Dates of Employment: From - to*
    Please enter a value
  63. Salary*
    Please enter a value
  64. Are your employment circumstances likely to change in the period of the tenancy/the next year?(*
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  65. If yes, please provide details
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  66. 6. Housing Benefit / Local Housing Allowance
  67. Are you claiming Housing Benefit / Local Housing Allowance? *
    Please specify a value
  68. If yes, please provide: Date of Last claim
    Please enter a value
  69. Name of Local Authority
    Please enter a value
  70. If no, but you do intend to, what forms of identification verification do you intend to produce?
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  71. 7. Other
  72. Do you have any pets? *
    Please specify a value
  73. If yes, please detail
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  74. Do any of the proposed occupants smoke? *
    Please specify a value
  75. 8. Applicant's Consent
    I hereby expressly consent to my personal details including any forwarding address at the termination of any tenancy being passed to the landlord and/or to the utility company and/or to the local authority. I understand that other than for reasons outlined above, all information will be treated as confidential.
  76. Signature (Please print your full name)*
    Please enter a value
  77. Date

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  78. 9. Declaration
    11.1. I am applying for a tenancy on the basis that the property or accommodation will be my main or only home.
    11.2. I give permission for enquiries to be made based on the information I have provided to establish my status.
    11.3. I also certify that I do not
    • have any County Court Judgements against me
    • owe money to any Housing Benefit Department or any Local Authority
    • owe monies or dilapidation monies to any previous Landlord
    • have substance or alcohol abuse problems.
  79. Signature (Please print your full name)*
    Please enter a value
  80. Date

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  81. IF YOU KNOWINGLY SUPPLY FALSE INFORMATION IT MAY BE USED BY THE LANDLORD TO SEEK POSSESSION OF THE PROPERTY UNDER GROUND 17 OF SECTION 8 OF THE HOUSING ACT 1988 (AS AMENDED BY SECTION 102 OF THE HOUSING ACT 1996). The information on this form is for the sole use of the landlord only for the purposes of letting. No information contained therein will be divulged to any third party, unless the Tenant defaults.
  82. 6a. Additional Financial Information
  83. Retirement Pension
    Please enter a value
  84. Other Income
    Please enter a value
  85. Property Applying for*
    Please enter a value