Application for Outer South

Rooming House Accommodation

Date of Application / //
Name of Applicant
Rooming House Applied for / (please indicate)

Dandenong Frankston

PLEASE COMPLETE ALL SECTIONS AND RETURN TO WAYSS LTD.
Mailing Address / PO Box 3 Dandenong Vic 3175
Fax No: / 9793 5078

WAYSS Office Use Only

Previous Tenancy / Yes No / Date Vacated / //
Outstanding Arrears / Yes No / Amount Owing / $
Previous antisocial behaviour / Yes No
Comments:
Applicant placed on waiting list / Yes No
Entered in CODA / Yes No / Date entered / //
Interview date / // / Sign up date / //

DETAILS OF APPLICANT

Mr Mrs Ms Miss / Date of Birth / //
Family Name:
Given Name/s:
Current Address:
Suburb: / State / Postcode
Contact Numbers: / Work / Home
Mobile / Other
Emergency Contact / Name / Phone
Employment Details
Income Type / Centrelink / Other
Centrelink Reference Number (CRN)
Nationality and Language Details:
Are you an Australian Citizen / Permanent Resident? / Yes No
Aboriginal/Torres Strait Islander? / Yes No
Country of birth
Main Language / Interpreter required / Yes No
Proficiency in written English Good Translation required

DETAILS OF REFERRING AGENCY

Referring Agency Name
Case Worker
Phone / Wk. / Mb.
Fax
Agency Address
Manager/Coordinator

APPLICANT’S SUPPORT NEEDS

Does the applicant have any additional requirements eg. Furniture? / Yes No
If yes, please state what is required.
Are there any health or disability issues that may affect the client’s housing needs. Yes No
If yes, please state nature of issue / Hearing impaired / Sight impaired
Other (please detail)
Are modifications to accommodation required? / Yes No
If yes, please state requirements
Does the applicant have ongoing support needs? / Yes No
If yes, please indicate type of support. / Medical / Drug Alcohol
Behavioural / Mental Health / Meals on Wheels / Other (detail below)

Details Of Support Agency

Agency Name
Case Worker
Phone / Wk. / Mb.
Support Details
Is there a support/case plan? / Yes No
Other relevant information
Is support from this agency likely to cease or change during tenancy period? / Yes No

GENERAL INFORMATION

Current Housing Status:
Private Rental / Public Housing
Long Term Community Housing (With another not-for –profit organisation) / Crisis Housing
Private Boarding/Rooming House / Caravan Park
Refuge / THM Program Housing
No fixed address
(Staying with Friends/Family) / No fixed address – Homeless (Parks/Streets/Homeless Shelters)
Purchasing/Purchased Own Home / Institutional Setting
Other – Please Specify / Unknown
Number of weeks in current housing
Reason for Leaving:
Conflict with neighbours / Housing unsuitable
Evicted for anti-social behaviour / Impending eviction
Evicted for rent arrears / Need to change location
Evicted – end of 120 day NTV / To live with friends
Housing not affordable / To live with relatives
Number of housing moves in last 12 months

RENT PAYMENT METHOD

CENTREPAY (Directly from applicant’s Centrelink payment)
Other

CHECKLIST - The following are required to be submitted with this application.

Client Consent Form attached / Yes
Income Statement attached / Yes
Identification attached / Yes
Doc No: 251
Version: 6Issue Date: 2/5/2012 / Author: RMA
Authoriser: GMQA / Approved by: GMQA
UncontrolledCopy When Printed / Page 1 of 4