HENDON CHRISTIAN HOUSING ASSOCIATION LIMITED

WAITING LIST APPLICATION FORM

FOR THOSE WITH A VISUAL IMPAIRMENT

______

When completed, this Form must be returned to:

Mrs. J. Patel, Hendon Christian Housing Association, c/o Fifield Glyn, 20 / 22 Station Road, Edgware, Middx. HA8 7AB.

PERSONAL DETAILS

1. Full Name / ______
2. Present Address / ______
3. Telephone No.
& e.mail / Evening: ______
Day: ______
Mobile: ______
e.mail ______
4. National
Insurance No. / ______
Please note that at the time of any offer being made, we will require proof of Identity / right of residence in the UK. This can be a Passport, Driving Licence, Birth Certificate or other original document containing relevant details.
5. Date of Birth / ______
6. Next of Kin / Name: ______
Address: ______
______
Relationship: ______
Mobile No: ______
7. Current Landlord’s
Details / Name: ______
Address: ______
______
Telephone No. ______
8. Type of
Accommodation
Required / ______
9. Why is Other
Accommodation
Required / ______
10. Other Members
of Your House-
hold Requiring
Accommodation.
Do you have a
Guide Dog? / Name Sex Relationship Age
______
EMPLOYMENT
DETAILS
11. Current
Occupation / Self ______
Please list anyone else in household over 16
who is employed
Name: ______
Occupation: ______
12. Applicant’s
Current Employer
Details / Name: ______
Address: ______
______
Tel. No. ______
13. Details of Income / Weekly/Monthly Income £ ______
Sources: ______
______
MEDICAL FACTORS
14. Visual Impairment
Registration
Details / Date of Registration: ______
Authority With
Whom Registered: ______
15. If not totally blind
indicate degree
of vision.
16. Would you like
any future
correspondence
in Braille or
please specify
pitch needed / ______
______
______
17. Mobility in Home
18. Other Disabilities
or Medical
Conditions / ______

Signature of Applicant ______

If signed by the Nominee

please print name here ______

Date:______

Data Protection and GDPR

To provide the Residential Management Service, Fifield Glyn Limited need to hold information including processing any necessary personal data of the Applicants, Residents and Tenants together with other information which are in Fifield Glyn's reasonable opinion necessary for the purpose of providing the Service. Fifield Glyn Limited is registered with the Information Commissioner’s Office and will take all reasonable measures to comply with the Data Protection Act 1998 and the General Data Protection Regulation. For further information go to: .

Supplementary Information

If there is a need to give extra information because of insufficient space in any of the boxes or there are other matters you wish to make us aware of, please use the space below or continue on an additional sheet

On the next page, there is an Ethnic Monitoring Form which we would like all applicants to complete. This information will remain totally confidential. Refusal to complete the Form will in no way affect the manner in which your application is dealt with.

May 2018