Q1.
First name.
Q2.
Surname.
Q3.
Date of Birth.
12345678910111213141516171819202122232425262728293031JanFebMarAprMayJunJulAugSepOctNovDec2017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930
Q4.
Sex.
Male Female
Q5.
Occupation on arrival at Arthur West House.
Q6.
Passport or national insurance number.
Q7.
Nationality.
Q8.
Home or family address.
Q9.
Employer or college address in London.
Q10.
Home or family telephone number.
Q11.
Employer or college telephone number in London.
Q12.
Home or family email address.
Q13.
Employer or college email address or website.
Q14.
Your mobile telephone number in London.
Q15.
Your email address.
Q16.
In which wing of Arthur West House are you applying to be housed?
The Hyelm Wing The Ames House Wing Either
Q17.
Would you be prepared to accept accommodation in the other wing if a space became available earlier and you met the relevant resident eligibility criteria?
Yes No
Q18.
What type of room do you prefer?
Small Twin Medium Twin Large Twin Standard Single Single with Shower
Q19.
Would you be prepared to accept another type of room if one became available earlier?
Q20.
Are you a smoker?
Please note that it is illegal to smoke in bedrooms that are shared by two or more residents at Arthur West House and in the property’s guest rooms, offices, communal areas, corridors, stairwells, lifts, sports and leisure facilities, service rooms, stores and areas of the courtyard, gardens and surrounding grounds that are enclosed or substantially enclosed places.Although it is not illegal to smoke in single bedrooms and in areas of the courtyard, gardens and grounds that are not enclosed or substantially enclosed places, residents and their invited guests are requested not to do so.
Q21.
Please give details of any disabilities that you have.
Q22.
Do you require accommodation or facilities designed for wheelchair use?
Q23.
Please outline any other personal circumstances that you would wish to be considered in your application.
Q24.
Please outline any other special requirements that you have in relation to your room that you would wish to be considered in your application.
Q25.
Please select which will best describe your circumstances if your application for accommodation at Arthur West House is successful:
Working full-time (over 24 hours a week) Working part-time (under 24 hours a week) Full-time student Part-time student On a Government training scheme Other (please give details below)
Q26.
If your application is successful, what will your total weekly income be once you have arrived at Arthur West House after deducting tax and national insurance?
Q27.
Please select which best describes your reason for applying to live at Arthur West House:
To enable me to come to London to work To enable me to come to London to study My present accommodation in London is not affordable My present accommodation in London is not suitable for other reasons I am currently homeless Other (please give details below)
Q28.
Please select which best describes what your alternative housing options would be if your application to stay at Arthur West House were unsuccessful:
I will be able to live with family or friends I will be able to rent or buy a property in the private sector I have no alternative housing options Other (please give details below)
Q29.
How did you first hear about Arthur West House?
From the internet From my employer or college From a housing agency From an advert From a friend or relative From the local authority Other (please give details below)
Q30.
From which date do you require accommodation?
Q31.
For how long do you intend to live at Arthur West House?
Q32.
If you already live in London, how long is it since you arrived?
Less than 4 weeks Between 4 weeks and 3 months Between 3 months and 6 months Between 6 months and a year More than a year I have lived in London all of my life
Q33.
Have you ever been made to leave or been evicted from accommodation in the past?
No Yes (please give details below)
Q34.
How would you like us to formally notify you of our decision on this application?
By post to my home / family address By email to my email address Other (please give details below)
Q35.
Please confirm that the information you have provided on this form is true and accurate by ticking the box below:
Yes, I confirm that the information I have provided is true and accurate
The following questions have been designed to assist us in implementing and monitoring our equalities policy.
If you prefer, you do not have to answer any questions within this section.
Q36.
Please tick the box which best describes your ethnic origin:
White - British White - Irish White - Other Mixed - White & Black Caribbean Mixed - White & Black African Mixed - White & Asian Mixed - White & Other Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Other Black or Black British - Caribbean Black or Black British - African Black or Black British - Other Chinese or Other Ethnic Group - Chinese Chinese or Other Ethnic Group - Other I prefer not to answer this
Q37.
Religious Belief:
Bahai Buddhism Christianity Hinduism Islam Jainism Judaism Sikhism Rastafarianism Zoroastrianism (Parsi) I have no religious belief I prefer not to answer this
Q38.
Please state whether you have a disability:
Q39.
If yes, please select which best describes your disability
Mobility Impaired Hearing Impaired Visually Impaired Physical Disability Other
