Expression of Interest (Centenary Close)

Expression of Interest (Centenary Close)

Ex- Services Scheme - Maryport

About you Joint Application

MR / MRS / MS / MISS / MR / MRS / MS / MISS
First name
Surname
Date of Birth
Current Address
Relationship to you

We can often provide you with a quicker service if we have all your main contact details.

Home phone
Work phone
Mobile
Email

Who owns your current home e.g. landlord, parent, Service quarters, private landlord, building society?

Current landlord (if applicable)
Phone number
Address
Tenancy from / Tenancy to
Why do you want or need to move into Centenary Close?
What is the notice period required on your current Service accommodation?
Service/Ex Service Number
Branch served
& proof of service
How many bedrooms do you require?
Ground or First floor? / One or two Bedrooms
Ground or first floor
Do you have any pets? / No Yes If yes, what type(s)?
Do you or the joint applicant have a tenancy of any residential property? / YES / NO
Your additional comments

Anyone who supports you or who do you get Care from?

If you have a Social worker, Support worker, Services Welfare or Unit Commander, Family member, Friend or Carer who helps you and you would like them to help you in future when we contact you, please give us their name and contact details (including their phone number)

Contact 1 Contact 2

MR / MRS / MS / MISS / MR / MRS / MS / MISS
First name
Surname
Address
Home phone
Mobile
Relationship to you .
What type of support do they give?

Disabilities

Do you or anyone living with you consider themselves to have a disability Yes No Household member affected (name please)
Uses a wheelchair
Walks but has mobility issues
Is blind or has sight problems
Is deaf or has hearing problems
Has learning difficulty
Depression, anxiety, self-harm mental–health
Long-term health problems
Has a disability not mentioned above
Use illegal drugs
Currently using any prescribed drugs?
In the past have you / they had problems with being violent or aggressive towards others others?
Do you have any convictions for arson?
Convictions/cautions/warnings against you?
Are you experiencing domestic abuse? / Yes No
Please use this space to add additional comments about the above
Do you have any problems in your current accommodation / No Yes
If yes, please give brief details:
Home Group is committed to eliminating discrimination and promoting equality of opportunity. To ensure this we monitor the race, ethnicity, gender and disability of all applicants. Your information will be treated in the strictest confidence and used only as described above. It will not form part of the decision making process. You do not have to complete this section if you don’t want to.
Gender / Male / Female / Transgender / Age
Do you consider yourself to have a disability? / Yes No
If yes, what sort of disability? / Sight impairment / Physical disability
Mobility / Hearing impairment / Learning disability
Progressive / Mental health disability / Prefer not to say
Wheelchair dependant / Occasional Wheel chair user
Difficulty turning/gripping with hands
Marriage/Civil Partnership
Married / Widowed / Divorced / Unknown/refused
Which group best describes your ethnicity?
Declaration: I confirm that the information I have given is correct. I understand that if any information I have provided is found to be false you may withdraw any service or offer of a service, including housing.
Signed (applicant) / Date
Print name
Your consent to contact your Support network about this application (Please sign if you are applying with the support of a referral agency)
I give my permission for staff at Stonham to discuss this application and all the information I have provided in this form with the referral agency named on page 1 of this form.
Signed / Date
Print name
Declaration: I confirm that the information I have given is correct. I understand that if any information I have provided is found to be false you may withdraw any service or offer of a service, including housing.
Signed (applicant) / Date
Print name
Your consent to contact your Support network about this application (Please sign if you are applying with the support of a referral agency)
I give my permission for staff at Stonham to discuss this application and all the information I have provided in this form with the referral agency named on page 1 of this form.
Signed / Date
Print name

Please send your completed expression of interest form to:

send electronic copy by e-mail to