Accommodation Application Form

1. Under which category for housing are you applying?

Which Housing Category?*

Direct Waiting List
Pathways Internal Transfer
Other Referral

Which Housing Scheme?

If you know the name of the scheme you wish to apply for, please specify it below:

Other Referral*

Please provide details, including the name of the organisation.

2) Personal Details

Full Name*

Date of Birth*

DD

MM

YYYY

Marital Status

National Insurance Number*

Please provide your National Insurance Number. It’s on your National Insurance card, benefit letter, payslip or P60. For example, ‘QQ 12 34 56 C’.

Are you a citizen of the UK or elsewhere in the European Union?*

Yes
No

Are you subject to immigration control?*

Yes
No

Proof of Status and Eligibiity*

Drop files here or

As you are not a UK/EU citizen or are subject to immigration control, you will need to provide a copy of your status papers and proof of your eligibility for social housing. Allowed files include jpg, jpeg, gif, png, bmp, pdf & tif. Maximum of 7Mb per file. Up to 10 files allowed.

Is this a joint application with another person?*

Yes
No

Name of Joint Applicant*

Please provide the name of the person you applying for a joint application with. Pathways may request further information about the joint applicant at a later date.

3) Contact Details

Telephone (Home)

Telephone (Work - If applicable)

Mobile Phone

Email address*

Enter Email Confirm Email

Next of Kin / Emergency Contact Details

Next of Kin Full Name	Relationship to you	Actions
		Edit Delete
There are no Next of Kin.

Maximum number of next of kin reached.

Please provide the contact details for one, but ideally two people who can act as your next-of-kin and be contacted in the event of an emergency.

4) About your present home

Full Address*

Please provide us with your full address below:

Street Address Address Line 2 City Postal Code Country

Proof of current address*

Please send us a photocopy of your passport or driver’s license AND two utility bills or bank statements as proof of current address. Allowed files include jpg, jpeg, gif, png, bmp, pdf & tif. Maximum of 7Mb per file. Up to 50 files allowed.

Drop files here or

How long have you lived at this address *

Number of Years*

Number of Months*

Other places you have lived in past 2 years

As you have indicated you have lived at your present address for less than 2 years, please provide the address(es) of the other place(s) you have lived in the past 2 years.

Previous Address	Actions
	Edit Delete
There are no Entries.

Maximum number of entries reached.

What kind of accommodation are you currently living in?*

Which of the following facilities do you share with others?*

Where you currently live, are you:*

The Private Rented Tenant
Living with family and/or friends
Homeless
Other

Landlord's Name*

Prefix First Last

Landlord's Address*

Street Address Address Line 2 City Postal Code Country

Landlord's Phone*

5) Expenditure, Income & Savings

Do you pay rent?*

Yes
No

How much is your rent?*

Please enter a number from 1 to 5000.

How often?*

Weekly
Monthly

Do you have any rent arrears?*

Yes
No

How much are your rent arrears?*

Please enter a number greater than or equal to 1.

Please explain why you are in rent arrears*

Have you ever been served with a Notice due to non-payment of rent?*

Yes
No

Please explain the circumstances of the Notice*

What other payments do you currently make?

Please provide average monthly amounts for all those that apply. Enter zero for those that do not apply.

Electricity*

Please enter a number from 0 to 999.

Gas*

Please enter a number from 0 to 999.

Television Subscription*

Please enter a number from 0 to 999.

Water*

Please enter a number from 0 to 999.

Telephone/Mobile*

Please enter a number from 0 to 999.

Council Tax*

Please enter a number from 0 to 999.

Other*

Please enter a number from 0 to 999.

Total

Do you currently undertake any form of work?*

(including full-time, part-time or voluntary work)

Yes
No

Details of Current Employment

Please provide details of any form of work (including full-time work, part-time work or voluntary work) currently undertaken by yourself.

Company or Organisation	Actions
	Edit Delete
There are no Employers.

Maximum number of employers reached.

Have you ever been filed for bankruptcy?*

Yes
No

On what date?*

Non-work related income

Please confirm how much of the following non-work related income (per month) and savings you have. Enter zero for those that do not apply.

Housing Benefit*

Please enter a number from 0 to 999.

Income Support*

Please enter a number from 0 to 999.

Support People*

Please enter a number from 0 to 999.

State Pension*

Please enter a number from 0 to 999.

Private Pension*

Please enter a number from 0 to 999.

Other Income*

Please enter a number from 0 to 999.

Total non-work Income per month*

(This is automatically calculated from your non-work related income inputs).

Total Savings*

Please enter a number from 0 to 9999.

6) Property Requirements

Which of the following do you require?

Please specify what other aids or adaptations*

7) Rehabilitation of Offenders Act 1974

Evictions*

Have you ever had a notice for eviction issued or been evicted?

Yes
No

Please specify details of the eviction or eviction notice:*

Convictions*

Have you ever been convicted for committing an anti-social behaviour offence, causing a nuisance, or been found in breach of your housing agreement?

Yes
No

Please specify details of the conviction(s):*

Have you ever been committed of an offence that is not spent?*

An offence leading to a sentence of imprisonment of more than two and a half years is never spent. Other offences are spent after a specified time-frame depending on the sentence.

Yes
No

Please specify details of the offence(s):*

8) Supporting Documentation

Please use the upload facility below to provide Pathways with any necessary supporting documentation, as outlined in the Accommodation Eligibility Criteria.

File Uploader

Drop files here or

Allowed files include jpg, jpeg, gif, png, bmp, pdf & tif. Maximum of 7Mb per file. Up to 50 files allowed.

9) Equality & Diversity Monitoring

Please help us to check and ensure that we are making our independent living accommodation schemes available to all eligible applicants by answering the following questions.

Gender*

Male
Female
Mixture of genders
Prefer not to specify

Disability (physical and mental health)*

Disabled
Not disabled
Mixture of abilities

Religion or belief*

10) Ethnicity Monitoring

Ethnic background*

White Ethnic Background*

Mixed/Multiple Ethnic Background*

Asian/Asian UK Ethnic Background*

Black/African/Caribbean/Arab/Black UK Ethnic Background*

Declaration

Health Declaration Upload*

Please upload a scan or photo of your completed Health Declaration Form, countersigned by your General Practitioner.

Declaration

I agree to the accommodation application declaration (below).

I declare that the statements made by me in this accommodation application are true and I agree to advise Pathways of any changes in respect to the information provided in this application as soon as they occur.

I understand that if I were found to have falsified information and therefore obtained housing by deception I may be prosecuted and may lose my home.

I agree that if I am offered accommodation, I shall occupy it as a beneficiary of the Charity and not as a tenant.

Any monthly or weekly sum I pay will be regarded as a maintenance contribution and not rent.

Privacy & GDPR*

I agree with the processing of my data by Pathways Housing.

Processing of your data is necessary in order to progress your request. The supplied data relating to you shall be kept for no longer than is necessary for the purposes for which it is being processed.

Additional Information

Please add below any further information that you feel may be relevant or assist us in dealing with your accommodation application:

Signature*

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Email

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