Housing Application Form
renting your home from us couldn’t be easier
Services offered by Four Housing
• Quality accommodation
• Comprehensive repairs service
• 24 hr Customer Service
telephone line
• Long term tenancies
• Comprehensive management
service
• Benefits advice
• Affordable rents
•
•
A range of 3,000 flats,
bungalows and houses from
South of the River Tyne to
North of the River Tees
Reassurance of renting from
a registered landlord
Renting a home from Four Housing
How do I apply?
Grade 2: A need to improve present living
arrangements
Simply complete an application form and return
it as soon as possible to the address on the
back of the leaflet. You can also ring 0300 00 44
444 or visit our website www.fourhousing.co.uk
to make an application.
Grade 1: In need of alternative accommodation
When a vacancy arises, we will look through our
waiting list, starting with those applicants in the
highest grade first.
If you require assistance in completing the
housing application form or further information,
please do not hesitate to contact Customer
Services on the above phone number.
How is my grade assessed?
This will be determined by the information
provided by you. Four Housing will consider the
reason why you want a home and determine
how much urgency there is for you to be rehoused. All information will be considered
including issues relating to:
• Overcrowding
• Medical Need
• Living Closer to work
• Affordability
• Transfers
• Homelessness
• Harassment
• Poor living conditions
• Insecure Tenancy
• Under occupation
• Caring arrangements
Who can apply?
Anyone aged 16 or over can make an application
for accommodation with Four Housing.
Applications from those aged 16 and 17 will
be considered if we think you can manage a
tenancy satisfactorily and you have a reliable
guarantor.
Will I automatically be considered
for accommodation?
Yes, you will be placed onto our waiting lists and
considered for suitable vacancies in your chosen
areas. However, Four Housing can refuse to
consider your application if you have a history
of criminal activity, anti-social behaviour, serious
rent arrears, violence or damage to property.
How will I know my application
has been registered?
What properties can I apply for?
Once your application has been registered onto
our waiting lists you will receive a confirmation
letter through the post.
The letter will confirm your application reference
number (you should quote this number when
contacting the Association), your grading and
the scheme waiting lists you have been placed
on.
Please check the property list carefully before
making your choice of areas on your application.
You are not restricted to the number of schemes
you can be considered for.
How do we allocate homes?
Four Housing grades all housing applications
according to their personal circumstances. We
take into consideration the medical, social and
housing needs of all applicants and award one
of three grades:
Will I need to provide evidence in
support of my application?
The Association will request that you provide
evidence to support your housing application.
Grade 3: In urgent need of accommodation
1
What should I do if my
circumstances change?
of your application and discuss your housing
requirements. The interview will also give you the
opportunity to ask any questions regarding your
application.
Contact us as soon as possible. Your application
can then be amended to reflect your current
housing situation. Your grading may be affected
by your change of circumstance.
The Association will also take up references to
assess your suitability for re-housing prior to any
offer accommodation. For example, we may
request that you provide a reference from your
previous or current landlord(s).
What if there is more than one
applicant with the same grade?
Four Housing will take into consideration the
length of time applicants have been on the
waiting list. The Association will therefore
consider those applicants that have been on the
waiting list the longest.
Offer of Accommodation
How can I increase my chances of
being re-housed?
Review of Waiting List
If you are offered a property you will be given the
opportunity to view the property before deciding
whether to accept.
Each year the Association reviews all applications
on the waiting lists. This is to ensure that the
waiting lists are kept up to date. Applicants who
do not respond to the revision letter will have
their application withdrawn from the waiting lists.
Four Housing works with a large number of local
Councils. The nomination agreements we have
with them means that on a large number of our
schemes 50% of vacancies have to be made to
people who the local council nominate to us. On
some schemes this percentage maybe higher.
You could increase your chances of housing by
applying to the local council or to a local choice
based letting partnership.
Data Protection
Any information supplied by you will be treated
confidentially and used only in connection with
your application.
How long will I have to wait until I
am offered accommodation?
Equality and Diversity
We aim to ensure that everyone who applies for
re-housing is treated fairly, irrespective of colour,
ethnic or national origin, nationality, gender,
sexual orientation, marital status, physical or
learning disability, age or religion.
This is a very difficult question to answer. The
length of time it may take to receive an offer of
accommodation depends on your needs and
circumstances, the type of property you need
and the availability of such properties in the
areas you have chosen. We could not guarantee
that you would ever be offered accommodation
especially in very high demand areas and any
offer of accommodation would be subject to
satisfactory references. This makes it extremely
difficult to estimate waiting times with any great
deal of accuracy.
Can I get further information?
Yes, a full copy of the Four Housing allocation
policy is available on request. Simply give us a
ring and we will send you a copy.
What if I am unhappy with the
service provided?
What happens if I am short listed
for accommodation?
We will contact you either by letter or phone
call to arrange an interview with you in your
present home or at one of our offices. The
purpose of this interview is to confirm your
present circumstances, confirm the details
If at any time you are dissatisfied with the way
your application has been dealt with, then you
can have your grievance considered through the
Group’s complaints procedure. Simply give us a
ring and we will help you.
2
Housing Application Form
1. How did you find out about Four Housing?
Poster Leaflet Internet Word of mouth/Recommendation Newspaper/Magazine (Please State) Housing Advice (CAB/Local Authority) Telephone Directory
Special Campaign
Other (Please State)
2. Are you a member of staff or known or related to any staff or committee members
of Four Housing?
No Yes (please give name)
3. Please list each person to be rehoused, including yourself.
Title First Name
Last Name
Sex (Male / Female
/Transgender)
Date of
Birth
4. National Insurance Number details
Applicant:
Partner:
5. Contact Details
Tel. No. (Home):
Mobile No.:
Email:
3
Relationship to Applicant
Current Address
Address
Postcode:
Date moved in to current address:
Landlord details
Name and address of Landlord (if rented):
Please advise your next of kin details
Tel. No. (Home):
Name/Address
Mobile No.:
Email:
Relationship to Applicant:
6. What type of applicant are you?
Council Tenant Hsg Assoc Tenant Tied Tenant No Fixed Abode HM Forces Private Tenant 7. What type of home do you live in?
House
Hostel
Flat
Bungalow
Sheltered
Bedsit
Living with Friends Hostel Living with Family Caravan
Other (Please State)
8. How many bedrooms does your home have?
Bedsit
One
Two
Three Four
Five+
4
Owner/Buying
Bed & Breakfast
Other (Please State)
9. Please list all the addresses you and your partner (if applicable) have lived in, in the
last 10 years.
Address
From/To
Tenure
(see question 7)
Landlord (if rented)
Name / Address
Reason for Leaving
10. Why do you want to be rehoused? (Please tick all appropriate boxes)
Better location To provide / receive medical support
In Prison Living with friends
Need to receive/provide support Sharing living facilities
House too big Overcrowded
Suffer from nuisance Threatened with eviction
General ill health To be nearer work
To be independent Severe medical need
Want to transfer Suffer from severe harassment
Relationship Breakdown Poor health prevents me living in home
Student with no / insecure tenancy Threatened with violence
Immediate family is split Sleeping rough
Cannot afford present home Other (Please State)
Have a tenancy less than six months
Poor condition of property
11. Please give details which you feel are important to your application. If you can supply
any evidence in support of your reasons, we can take this into account.
5
12. What type of accommodation would you like? (Tick appropriate boxes)
Flat Bungalow Bedsit
House Sheltered
13. How many bedrooms would you like?
Bedsit
One Three
Two
Four +
14. CRIMINAL CONVICTIONS (Please list any convictions by you or your partner which
are not spent – the Association carries out checks with the police – if you do not
disclose information it may prejudice your application)
15. Have you also applied for Housing through your local Council?
Yes No
16. DECLARATION
To the best of my knowledge the above information is correct. I understand that if I make false
statements to try to obtain housing deceitfully, my name will be removed from the waiting list, or any
property allocated to me may be repossessed. I also authorise Four Housing to obtain information and
make enquiries, should they be necessary to my application.
Signed (Applicant)
Date
Signed (Joint Applicant)
Date
Please now complete the sections on Places you would like to live and Customer Information.
6
Places you would like to live
(Please tick all appropriate boxes).
F=Flat H=House B=Bungalow
No.of Suitability
Demand Type units (E - Specifically for people over 55)
Chester-le-Street
No.of
Bedrooms
1 2 3 4
Church Chare
•
Medium
F
6
Single, Couple
Morningside Court
E
Low
F
23
Over 55, applicants over 45 welcome
High
H/B
15
Single, Couple, Over 55, Family, Wheelchair user
High
H
1
Family
Medium
F
12
Over 55 (single/couple)
High
B
10
Eco Bungalows
E• •
Pelton
Darlington
1
2
4
•
Bright Street, Eastbourne
Dene Park Court, Corporation Road
3
E
E
Edgemoor Road, Firthmoor
Hartington Way, off Brinkburn Road
•
High
H
1
Family
Lazenby Crescent, Mowden
•
High
H
1
Family
Major Street, The Denes
•
High
H
1
Couple, Family
Newton Lane
E
High
B
3
Over 55 (single/couple)
Railway View, Pudsey Walk, Parkside
E E• •
High
H/B
26
Over 55, Family, Wheelchair user
Skeldale Grove, off Brinkburn Road
•
High
H
1
Couple, Family
Smithfield Road, Parkside
E
High
B
20
Over 55 (single/couple)
Ullswater Avenue
E
High
B
8
Over 55
High
B
13
Over 55 (single/couple)
Low
H
5
Family
Medium
H
9
Couple, Family
Low
F
12
Singles, Couple
Derwentside
1
2
4
E
Birch Crescent, Burnopfield
•
Pelaw Mews, East Stanley
•
Railway Street, Langley Park
Rivers Estate, South Stanley
3
•
Sandalwood Walk, East Stanley
E
High
B
5
Over 55 (single/couple)
South Moor
•
Low
H
61
Over 55 (single/couple)
High
F
9
Singles, Couple
High
B
18
Over 55 (single/couple)
High
F
9
Singles, Couple
Durham
Allergate, City Centre
1
•
E
Cook Av/Kingston Av/Mullin Cl, Bear Park
Belle Vue Court, Gilesgate
2
•
3
4
7
F=Flat H=House B=Bungalow
Durham (Continued)
No.of
Bedrooms
1 2 3 4
Belle Vue Court, Gilesgate
•
•
Broomside Lane, Belmont
No.of Suitability
Demand Type units (E - Specifically for people over 55)
High
F
9
Singles, Couple
High
H
2
Family
Charlton Court, Bowburn
E
Medium
B
8
Over 55 (single/couple)
Crescent Close, Sherburn Village
E
High
B
8
Over 55 (single/couple)
Crossgate, Durham City
E
High
F
6
Over 55 (single/couple)
Doric Road, New Brancepeth
•
Medium
H
20
Couple, Family
High
F
10
Singles, Couple
•
Medium
F/H
46
Singles, Couple, Family
•
High
H
1
Family
•
Medium
F
32
Singles, Couple
•
High
H
4
Couple, Family
•
Medium
F
8
Singles, Couple
Griffiths Court, Bowburn
E•
High
F/B
18
Single, Couple, Over 55
Haven Court, Pity Me
•
High
H
1
Couple, Family
Horton Crescent, Bowburn
E• •
High
H/B
19
Single, Couple, Over 55, Family
Douglas Villas, Claypath
•
Dunelm Court, Brandon
•
•
Esh Wood View, Ushaw Moor
Forest View, Brandon
•
Gilesgate, Durham
Green Court, Gilesgate
•
•
•
79 High Street South, Langley Moor
•
High
H
1
Family
16 John Street South, Meadowfield
•
High
H
1
Family
•
High
F/H
20
Singles, Couple, Over 55, Family
Lantern Court, Gilesgate
•
•
Lund Court, Framwellgate Moor
E
High
B
9
Over 55 (single/couple)
Magdelene Avenue, Belmont
E
High
B
3
Over 55 (single/couple)
Millhouse Court, Gilesgate
E
High
B
2
Over 55 (single/couple)
Philip Avenue, Bowburn
E• •
High
F/B
17
Single, Couple, Over 55, Family
Priory Orchard, City Centre
•
•
High
F
14
Single, Couple
Redwood, Brandon
•
•
Low
F
18
Single, Couple
High
H
14
Family
Roselea, Witton Gilbert
•
Runcie Road, Bowburn
•
High
H
2
Family
School Avenue, West Rainton
• E• •
High
F/H/B
36
Single, Couple, Over 55
Sherburn Road Estate
•
High
F/H/B 169 Single, Couple, Family
St Agathas Close, Brandon
•
High
F/H
39
Single, Couple, Family
High
F
33
Over 55, applicants over 45 welcome
High
F
5
Single, Couple
Medium
H
10
Single, Couple, Over 55, Family
Whitwell Court, Sharp Crescent, Gilesgate
•
•
E
St Margarets Court, City Centre
Waterson Crescent, Witton Gilbert
•
•
•
•
•
8
F=Flat H=House B=Bungalow
Easington
No.of
Bedrooms
1 2 3 4
No.of Suitability
Demand Type units (E - Specifically for people over 55)
Ash Grove, Trimdon
E
Medium
B
8
Over 55 (single/couple)
Eden Hill, Peterlee
•
Low
F
6
Single, Couple
Fairclough Court, Peterlee
•
High
F
9
Single, Couple
Medium
F
10
Single, Couple
Parkside (Beech Crescent), Seaham
•
Thornley
•
•
High
H/B
40
Single, Couple, Over 55, Family, wheelchair user
Grange Court/Brandling Court, Shotton
•
•
Medium
H/B
12
Single, Couple, Over 55, Family, wheelchair user
2
3
Medium
F
26
Single, Couple
Medium
H
1
Family
Medium
F
4
Single, Couple
Gateshead
1
Belgrave Court, Shanid House, Felling
•
•
Borrowdale Gardens, Beacon Lough
Clayton Terrace, Felling
4
•
•
Cromwell Street, Mount Pleasant
•
•
High
H
12
Couple, Family
Halcyon Place, Carr Hill
E
•
High
B
12
Over 55 (single/couple)
Holly Park View, Felling
E
E
High
F
32
Over 55 (single/couple)
Howe Street, Felling
•
•
Medium
F
2
Single, Couple
High
H
15
Couple, Family
Medium
F
4
Single, Couple
High
H
5
Family
Medium
H
26
Family
Medium
F
31
Single, Couple
High
H
15
Family
Medium
F
3
Single, Couple
Medium
F/H
27
Over 55, Couple, Family
Medium
F
2
Single, Couple, Family
Medium
F
5
Single, Couple
•
Marys Place, Sheriff Hill
Moore Street, Felling
•
•
•
Millway Close, Sheriff Hill
•
Newman Place, Old Durham Road
•
Nile Court, Felling
•
•
•
Seymour Street, Dunston
Shanid House/South View, Felling
•
Stephenson Terrace, Felling
E
Sunderland Road, Felling
•
Stileford, Leam Lane Estate
•
•
Hartlepool
1
2
3
Arch Court, Central Estate
•
•
•
Low
F/H
27
Single, Couple, Family
Brunel and Telford Close, Central Estate
•
•
•
Medium
F/H
24
Single, Couple, Family
Central Buildings, Church Street
•
•
Medium
F
21
Single, Couple
Church Street, Town Centre
•
•
Medium
F
8
Single, Couple
Elliott Street/Hartley Close/Derwent Street •
•
High
F
20
Single, Couple
Ensign Court, Marina
•
•
High
F/H
46
Single, Couple, Family
Friendship Lane, Headland
•
•
•
High
F/H
35
Single, Couple, Family
•
•
High
H/B
9
Couple, Family, Wheelchair user
Hilda Walk, Burbank
•
•
•
4
9
F=Flat H=House B=Bungalow
No.of Suitability
Demand Type units (E - Specifically for people over 55)
Hartlepool (Continued)
No.of
Bedrooms
1 2 3 4
Lancaster Court, Lancaster Road
E• •
•
Medium F/H/B
41
Single, Couple, Over 55, Family
•
•
Medium
H
26
Couple, Family
High
F
6
Single, Couple
High
H
6
Family
Medium
F
36
Over 55 (sheltered scheme)
Longscar Walk, Burbank
Moor Terrace, Headland
•
•
Raby Street /Church Walk, Headland
Schooner Court, Marina
E
Southgate, Headland
•
•
High
F
5
Single, Couple
St Columbus Court, Dryden Road
•
•
Medium
F
12
Single, Couple
Thornhill Place, Hart Lane
•
E
High
F
14
Over 55 (single/couple)
Thornton Street, Town Centre
•
Low
F
3
Single, Couple
Thorpe Street, Headland
•
High
F/H
8
Single, Couple, Family
Medium
H
1
Family
High
H
17
Couple, Family
High
H
1
Family
Medium
F
8
Single, Couple
High
H
1
Family
Over 55 (single/couple)
•
•
•
Vane Street, Headland
Newcastle
Brigham Avenue, Kenton, Newcastle
1
Redcar & Cleveland
Burnmoor Drive, Eaglescliffe
1
2
3
4
•
•
3
4
•
•
The Gables, Redcar
Sedgefield
Atherton Close, Spennymoor
2
1
2
3
•
4
Bamburgh Parade, Spennymoor
E
High
B
31
Dean Bank, Ferryhill
•
Low
H
107 Single, Couple, Family
Ferryhill Station
E• •
Flambard Court, Bishop Middleham
E
Ivy Close, Spennymoor
•
Kenmir Court, Spennymoor
E
Kerr Crescent, Sedgefield
•
8
Over 55 (single/couple)
High
H
25
Couple, Family
High
B
16
Over 55 (single/couple)
High
F/H/B
5
Single, Couple, Over 55, Family
High
B
15
Over 55 (single/couple)
High
H
1
Family
E
Low
F/B
40
Over 55 (sheltered scheme)
E
High
B
13
Over 55 (single/couple)
Medium
H
1
Couple, Family
E
Park View, Shildon
•
•
•
E
Over 55, Single, Couple, Family
B
Lockyer Crescent, Newton Aycliffe
The Garth, Ferryhill
44
High
E
Ladysmock Close, Spennymoor
Medium F/H/B
•
Rushmoor, Spennymoor
St Pauls Court, Spennymoor
E
High
B
8
Over 55 (single/couple)
The Mallards, Shildon
E
High
B
13
Over 55 (single/couple)
10
F=Flat H=House B=Bungalow
South Tyneside
No.of
Bedrooms
1 2 3 4
Three Rivers Court, West Boldon
Westoe Crown Village, South Shields
School Street, Hebburn
Hollystone Drive, Hebburn
Usway Close, Hebburn
Sinclair Meadows, South Shields
Colchester Street, South Shields
Sunderland
Alderley Close, Grangetown
1
Argyle Square, Ashbrooke
•
•
E
•
•
•
•
•
•
•
•
•
•
•
•
•
2
3
4
High
High
High
High
High
High
High
H
H/B
H
H/B
H
F/H
H/B
8
30
41
31
16
21
12
Couple, Family
Over 55 (single/couple)
Single, Couple, Family
Couple, Over 55, Family
Couple, Family
Single, Couple, Family
Couple, Over 55, Family
High
H
11
Family
Medium
F
4
Single, Couple
Medium
H
1
Family
Medium
F
10
Over 55 (single/couple)
Medium
H
1
Family
•
High
B
1
Single, Couple, Family
E
Medium
F
18
Over 55 (single/couple)
•
•
Bartram Street, Fulwell
E
Brandling Street, Roker
•
Croft Avenue, Chester Road
Grange Street South Grangetown
No.of Suitability
Demand Type units (E - Specifically for people over 55)
Ingleton Court, General Graham Street
E
Kipling Street, Southwick
•
Medium
B
2
Single, Couple, Over 55
Kismet Street, Southwick
•
Medium
B
1
Single, Couple, Over 55
High
H
1
Family
Medium
H
1
Couple, Family
•
Medium
B
1
Family, Wheelchair user
•
Medium
F/H
14
Single, Couple, Family
•
Lowthian Terr, Columbia, Washington
•
Margaret Street, Grangetown
Manor Lette, Washington
•
Moorland Square, Pallion
Morgan Street, Southwick
•
Medium
B
1
Single, Couple, Over 55
Osbourne Street, Fulwell
•
Medium
B
1
Single, Couple
•
High
F/H
50
Single, Couple, Family
Raydale, Redhouse
•
High
H
6
Family, Wheelchair user
Ramsey Square, Redhouse
•
High
H
1
Family
Medium
H
1
Couple, Family
Medium
F
2
Single, Couple
•
Pallion Park/Florida Street, Pallion
•
Rosebery Street, Newcastle Road
Rutland Street, Pallion
•
Serlby Close, Washington
•
High
H
10
Family
South View, Fatfield, Washington
•
Medium
H
1
Family
Summerhill, Durham Road
•
Medium
F
13
Single, Couple
The Limes, Ashbrooke
•
High
F
14
Single, Couple
Tower Court, Easington Lane
•
Low
F
20
Single, Couple
Victoria Place, Murton Street
•
Medium
F
19
Single, Couple
Villa Close Hylton Road
E
Medium
F
26
Over 55 (single/couple)
E
11
F=Flat H=House B=Bungalow
No.of
Bedrooms
Sunderland Continued
1
Victoria Place, Murton Street
•
Villa Close Hylton Road
E
Teesdale
Beaconsfield Court, Barnard Castle
Bedburn Road, Hamsterley
Birkett Close, Cotherstone
Farmers Way, Barnard Castle
Jubilee Terrace, Mickleton
Neville Close, Gainford
Salterburn Place, Butterknowle
1
Tannery Yard, Barnard Castle
The Old Court House
Vere Road, Barnard Castle
Wear Valley
2
4
E
2
E
E•
•
E E
•
E•
•
3
No.of Suitability
Demand Type units (E - Specifically for people over 55)
3
•
•
•
•
•
3
19
Single, Couple
Medium
F
26
Over 55 (single/couple)
12
8
12
15
7
14
6
10
7
1
Over 55 (single/couple)
Single, Couple, Over 55, Family
Couple, Over 55, Family
Over 55, Family
Family
Single, Couple, Over 55, Family
Family
Single, Couple, Over 55, Family
Single, Couple
Family
High
H
High
F/H/B
High
H/B
High
F
High
H
Medium F/H/B
High
H
High
F
High
F
High
H
•
•
2
F
4
•
1
Medium
4
Ashcroft/St. Thomas Close, Stanhope
•
Low
F/H
24
Single, Couple, Family
Attwood Terrace, Wolsingham
•
Medium
H
1
Couple, Family
Bourne Way, Willington
E
High
B
10
Over 55 (single/couple)
High
F
9
Single, Couple
Medium
F/H
12
Single, Couple, Family
High
B
19
Over 55 (single/couple)
High
H
1
Family
•
Medium
H
1
Couple, Family
•
Low
F
8
Single, Couple
•
High
H
1
Family
Medium
B
1
Wheelchair user
High
F/H
42
Single, Couple, Family
Bridge Street, Bishop Auckland
•
Chapel Street, Hunwick
•
•
Denewood Close, Willington
E
E
•
Durham Road, Wolsingham
Hood Street, St Johns Chapel
Laurel Gardens, Crook
•
•
Lister Terrace, Wolsingham
•
Lyndale, Wolsingham
Peacock Court, Bishop Auckland
•
Richardson Court, Willington
E
High
B
15
Over 55, Wheelchair user
Short Street, Bishop Auckland
•
Medium
H
1
Couple, Family
High
F/B
13
Single, Couple, Wheelchair user
Medium
B
6
Over 55 (single/couple)
•
Medium
H
2
Family
•
Medium
H/B
26
Over 55, Family, Wheelchair user
•
Medium
B
3
Wheelchair user
Medium
H/B
20
Over 55, Family
South End Villas, Crook
St Stephens, Willington
•
•
E
Uppertown, Wolsingham
Wesley View, Wolsingham
E
West End Villas, Crook
Westfield, Frosterley
•
E
•
•
12
Customer information
Four Housing is committed to equal opportunities and welcomes applications from all sections of
the community including those who are currently protected by law and those who are not.
To help us to make sure that our services are meeting the needs of all our customers or potential
customers we would like you to answer the following questions. This information is not part of your
application for housing and will not be taken into account when your application is assessed. If
you would prefer not to answer any of the questions in this section it will not affect your application
for housing in any way.
This information will be recorded by Four Housing for the purposes of service delivery. It will be
handled confidentially and in line with data protection requirements.
1. How would you describe your households ethnicity?
(If there is more than one ethnicity within your household please tick all that apply)
White
British Eastern European
Irish
Other Mixed
White and Black Caribbean
White and Black Asian
White and Asian
Other Black or Black British
Chinese
British
Chinese
African
Other
Other Asian or Asian British
British
Pakistani
Bangladeshi
Other
Other Ethnic Group
Other
Rather not say
2. What format would you prefer to receive information in?
No special requirements
Black print on white paper
Audio cassette
Black print on yellow paper
Email
CD
Large Print
DVD Other (please give details)
3. Is English your first language?
Yes
Text Message
Plain English
Picture Format
No
4. If English is not your first language what language would you like us to communicate
with you in?
5. And would you prefer written or spoken communications?
Written
Spoken
13
6. Do you or any household member consider yourselves to:
Have mobility or physical Have hearing or speech
difficulties
difficulties
Have issues with
Have learning, literacy or
mental health
numeracy needs
7. What is your current employment status?
Full time employed Seeking Work
Part time employed
Long Term Sick
Self Employed
Looking after home/carer
Have sight and vision
difficulties
Retired
Student
Training
8. How would you describe your household’s faith or religious belief? (If there is more
than one faith or religion within your household please tell us about all that apply) e.g.
Christian, Muslim etc.
Christian
Muslim
Sikh
Hindu
Catholic
Jehovas
Buddhist
Other
Jewish
Aethiest
Agnostic
None
9. How would you describe the sexual orientation of your household?
(If there is more than one sexual orientation within your household then please tick all that apply)
Straight/Heterosexual
Bisexual
Gay Man
Rather not say
Lesbian
10.To help us ensure that your personal information is kept secure please answer one
of the following security questions: (You may be asked to answer this question before we
discuss your application for housing, tenancy or other personal information with you.)
What is your mother’s maiden name?
What is your place of birth?
Where was your first school?
Thank you for your help.
14
Please return this form to:
Four Housing, Three Rivers House, Abbeywoods Business Park,
Pity Me, Durham, DH1 5TG
Telephone: 0300 00 44 444 Fax: 0191 386 3974
Email: contact@fourhousing.co.uk Web: www.fourhousing.co.uk