Q1.
First name.
Q2.
Surname.
Q3.
Date of Birth.
12345678910111213141516171819202122232425262728293031JanFebMarAprMayJunJulAugSepOctNovDec2017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930
Q4.
Sex.
Male Female
Q5.
Occupation.
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 type of cluster apartment are you applying for a room?
A three bedroom cluster apartment A four bedroom cluster apartment A six bedroom cluster apartment Any type of apartment
Q17.
Would you be prepared to accept accommodation in another type of cluster if a place in that apartment became available earlier?
Yes No
Q18.
Please give details of any other preferences that you have in relation to the cluster apartment or room in which you would like to be housed (e.g. the names of other residents or applicants with whom you would like to share)
Q19.
Would you be prepared to accept a room that did not meet these additional preferences if one became available earlier?
Yes No Not appropriate
Q20.
Please give details of any disabilities that you have.
Q21.
Do you require accommodation or facilities designed for wheelchair use?
Q22.
Please outline any other personal circumstances that you would wish to be considered in your application.
Q23.
Please outline any other special requirements that you have in relation to your room that you would wish to be considered in your application.
Q24.
Please select which will best describe your circumstances if your application for accommodation at Hyelm - Old Street 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)
Q25.
What is your total weekly income after deducting tax and national insurance?
Q26.
Please select which best describes your reason for applying to live at Hyelm - Old Street:
To enable me to move on from Arthur West House My present accommodation is not affordable My present accommodation in London is not suitable for other reasons I am currently homeless Other (please give details below)
Q27.
Please select which best describes what your alternative housing options would be if your application to stay at Hyelm - Old Street 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)
Q28.
How did you first hear about Hyelm - Old Street?
From 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)
Q29.
From which date do you require accommodation?
Q30.
Have you ever been made to leave or been evicted from accommodation in the past?
No Yes (please give details below)
Q31.
Are you a smoker?
Please note that it is illegal to smoke in shared kitchen/dining/living rooms within residents’ two, three, four and six bedroom cluster apartments at Hyelm – Old Street and in the property’s offices, communal areas, corridors, stairwells, lifts, sports and leisure facilities, service rooms, stores and areas of the courtyard, grounds and roof terraces that are enclosed or substantially enclosed places.Although it is not illegal to smoke in areas of the courtyard, grounds and roof terraces that are not enclosed or substantially enclosed places, residents and their invited guests are requested not to do so.It is not illegal and it is permitted to smoke in residents’ en-suite bedrooms and in kitchen/dining/living rooms within one bedroom flats. Residents are liable for the cost of any damage to their accommodation and/or to fixtures and fittings caused by smoking. Residents are also liable for the cost of additional cleaning and/or decorating that may be necessary in their accommodation, due to smoking, to keep it in the clean condition and good decorative order that is required under the terms of their Licence or other Tenancy Agreement.
Q32.
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)
Q33.
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.
Q34.
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
Q35.
Religious Belief:
Bahai Buddhism Christianity Hinduism Islam Jainism Judaism Sikhism Rastafarianism Zoroastrianism (Parsi) I have no religious belief I prefer not to answer this
Q36.
Please state whether you have a disability:
Q37.
If yes, please select which best describes your disability
Mobility Impaired Hearing Impaired Visually Impaired Physical Disability Other
