Title (Mr / Mrs etc)
Name
First Name
Last Name
Your date of birth
Your Email
Your Mobile Number
National Insurance Number
Nationality
If you are happy with the accommodation, how long are you planning to stay?
Do you have any pets?
Do you smoke?
Do you have any children who will be staying with you? (yes/No)
If children will be staying with you please list names, ages and genders
Do you have any county court judgments / bad debt? (if yes, give details)
Have you ever been evicted from previous accommodation? (if yes, give details)
Reasons you are moving?
Are you currently renting or staying with friend, relative?
If renting provide details below
Landlord / agent name
Landlord/Agent Tel. Number
Landlord / agent email
Your current address
Your previous address
If your previous address was a rental property, give details of landlord or agent (their name and contact details)
How long have you been in this address (years) ?
What is your current rent per month (££)
What benefits are you currently claiming?
How much are you claiming in benefits?
Are you currently claiming Housing Benefit?
Are you actively looking for work?
If not looking for work, why not? (Disabled? Long term sick?)
Do you currently work with a support worker?
Are you able to provide a guarantor?
Name of guarantor
Relation to you
Guarantor's phone number
Guarantor Email
Guarantor's current address
Guarantors current landlord/agent details (if this applies)
Is the guarantor in employment?
If yes, please give name of employer, address of employer and name of contact person at the company (to contact for an employment reference)
Please provide details of your next of kin (someone to contact in case of emergency)
Say "yes" here: I read the above statement and declare that the information I provided is correct.
Say "yes" here: By submitting this form I confirm that I have read and agree with your Privacy Notice
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