Housing application

Please answer all questions in full – all information will be treated in confidence.

Home Application

Your details

Title

First Name

Last Name

Telephone

Date of Birth

Address

Postcode

Health and medical circumstances

The Trust has a duty to ensure that accommodation is suitable for you. We must also be certain that all Personal Support Plans take account of health and medical needs in order for us to provide the appropriate type and level of support. In order for the Trust to comply with its legal obligations with regard to the safety, care and support of its residents, it requires details of any long term ailment or disability which may affect independent living.

Details of long term ailments or disabilities

Can you cook, shop and do housework, garden, climb stairs, bath yourself?

If yess

Are you registered disabled?

Support

Give information of close relatives or other persons who give you support.

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Name

Telephone

Relationship to you

Address

Residence in the area

If you are not a resident or have never been resident in Gosport, state your reason for wanting to move to the area

Give reasons for wishing to be housed by the Trust

Present accommodation

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Your present accommodation

Current rent £

Per

Please give details of the landlord/description of arrangements

Length of stay in years

If less than five years, please state your previous address

Do you have a pet?

Regrettably, dogs, cats and some other pets are not permitted in our accommodation. If you wish to bring a pet please check first with our head office.

Current property

Your current property is a..?

No. of bedrooms

If a flat, what floor is it on?

Details/description of your current property

Please tick all that apply:

Inside WC

Lift access

Outside WC

Stairlift

Bathroom

Central heating

Fuel types

Electricity

Gas

Other

Do you share part of your accommodation with people other than your partner?

If yes, please let us have the details

Do you have a house to sell?

If yes - is the home on the market?

Are you on the waiting list for any other housing such as council housing?

If yes please provide more details

Current council tax

Local council

Address

Property and capital details

If you own your property, what is its approximate value?

Is there an outstanding mortgage?

Current value of cash savings (bank, building society, PO etc)

If yes how much?

Current value of investments (shares, bonds, trust, property etc)

Current income

Total weekly income (including interest on savings?

Are you in receipt of housing benefit or Universal Credit?

Type of work

Equal Opportunities Monitoring

The John A. Thompson Memorial Trust is committed to providing sheltered housing and residential care to the diverse population we serve. It is vital that we monitor and analyse diversity information so that we can ensure that our processes are fair, transparent, promote equality of opportunity and do not have an adverse impact on any particular group. Your cooperation in providing us with accurate data will ensure that we not only meet our legal obligations, but even more importantly, will result in us designing and applying policies and processes that attract a balanced and diverse community to enjoy the benefits of Thorngate Living. Any information provided on this form will be treated as strictly confidential and will be used for statistical purposes only. No information will be published or used in any way which allows any individual to be identified.

APPLICANT

Gender

Married or in a civil partnership?

Age

What is your sexual orientation?

Do you consider yourself to be disabled?

What is your religion or belief?

Any information you provide here will be used for monitoring purposes only – if you need a ‘reasonable adjustment’, then please follow the additional separate process. We will take reasonable steps to meet your particular needs.

HOW WOULD YOU DESCRIBE YOUR NATIONAL IDENTITY?

Checkbox Field

English

Welsh

Scottish

Northern Irish

British

Other

Prefer not to say

HOW WOULD YOU DESCRIBE YOUR ETHNICITY?

White

English

Welsh

Scottish

Northern Irish

British

Gypsy or Irish Traveller

Other

Mixed / multiple ethnic groups

White and Black Caribbean

White and Black African

White and Asian

Other mixed background

Asian / Asian British

Indian

Pakistani

Bangladeshi

Chinese

Other Asian background

Black / African / Caribbean / Black British

African

Carribean

Other Black / African / Caribbean background

Other ethnic group

Arab

Any other ethnic group background

Prefer not to say

Confirmation of signature

To the best of my knowledge and belief the statements made in this application are true and correct.

Name

Date

We will use your personal information to decide whether to offer you accommodation and care. If successful in becoming a resident at The John A. Thompson Memorial Trust we will use your personal information in order to deliver an efficient and effective service as a registered provider of housing and social care. We may share your personal information with Hampshire County Council, Gosport Borough Council, Adult Services, your GP and/or the NHS only if sharing your personal data complies with our data protection policy. We will not share your personal information, without your consent, with any other organisation except to help prevent fraud or if required to do so by law. You have the right to request a copy of the personal information we hold about you. If you would like a copy of some or all of this please contact us at: 28 Festing Road Southsea Portsmouth, Hampshire P04 0NQ

Join Us

Housing application

Your details

Health and medical circumstances

Support

Residence in the area

Present accommodation

Current property

Please tick all that apply:

Fuel types

Current council tax

Property and capital details

Current income

Equal Opportunities Monitoring

APPLICANT

HOW WOULD YOU DESCRIBE YOUR NATIONAL IDENTITY?

HOW WOULD YOU DESCRIBE YOUR ETHNICITY?

Confirmation of signature

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