Applicant Form

Retrieve Existing Application

Are You An Existing PRHA Resident

Are you or anyone to be housed with you related to a PRHA member of staff or a member of its Board?

Personal Details

Salutation *

First Name *

Last Name *

Email *

Date of Birth *

Gender *

Mobile *

Contact Details

Current Address Line 1 *

Address Line 2

Town / City *

County

Postcode *

Country *

Length of Stay at Current Address *

If you have been at your previous address less than 12 months, please complete the box below.

If you have been at your current address less than 12 months, please input your previous address below.

Phone Home

Phone Work

Joint Application

Name of Joint Applicant

Next of Kin

First Name

Last Name

Phone Work

Mobile

Doctor Information

Name of Doctor

Practice and Address of Surgery

Residential Status

Do you and everyone to be housed with you have the right of residence in the UK?

Passport Number or Driver Licence

National Insurance Number

Visa Number (if applicable)

No of Years on Visa

Visa Type

Country of Origin

Please give brief details of your reasons for wanting to move to a PRHA property

Please input details below

Please indicate which applies to your current housing

Please select one of the following options

If other, please detail below

Your Current Accomodation

Please select one of the following

If Other, please give further details.

Do you have a pet?

What pet do you have?

If you rent your current home, please tell us the name and contact details of your previous landlord. Please note, PRHA may approach your landlord for a reference.

Landlord Name

Landlord Address Line 1

Landlord Address Line 2

Landlord Town/City

Landlord County

Landlord Postcode

Landlord Email

Landlord Contact No

As far as you're aware, do you owe rent appears to a current or former landlord, or do you owe mortgage appears?

Please provide details, including any plan to clear the arrears

Have you or anyone in your household been evicted from or been subject to possession proceedings within the last 2 years?

Please provide details if Yes

Have you or anyone in your household been served with a Community Protection Notice (CPN), CPW, ASB Order, Notice to Quite, Notice of Seeking Possession, Injunction or been asked to sign an acceptable behavior contract for Anti-Social Behavior within the last 2 years.

Please provide details below

Do you or anyone in your household have convictions for a criminal offence other than a spent conviction under the Rehabilitation of Offenders Act 1974?

Please provide details:

Do you or anyone in your household have a Probation Worker?

Please provide further details

Do you have a person or persons acting for you under a Power of Attorney?

Please provide further information

What type of accommodation do you wish to be considered for?

Number of Bedrooms

Area

Which Floor Level Would You Prefer?

If you wish to be considered for a 2 bedroom property, please explain why

Employment

Are You Currently Employed? *

How many hours do you work per week?

Place of Employment

Company Address Line 1

Address Line 2

Town / City

County

Postcode *

Hours Worked Per Week

Length of Employment

Housing Benefits

Are you in receipt of any Housing Benefits?

Where did you hear about PRHA?

Mobility and Well-Being

How would you describe your current mobility?

Are you able to climb stairs?

Have you been able to easily about your current home?

How frequently have you fallen and what seems to cause the falls?

Do you smoke or use alcohol?

Do you have any difficulty with any day-to-day tasks such as cleaning and cooking?

Do you use a mobility scooter?

Further Information

Any other information you would like to add as part of your application can be included here

Equality and Diversity Monitoring

Please help us to check and ensure that we are making our independent living accommodation schemes available to all eligible applicants by answering the following questions.

Gender *

Disability (physical and mental health) *

Religion *

Ethnicity Monitoring

Ethnic background *

Personal Details
Contact Details
Joint Application
Next of Kin
Doctor Information
Residential Status
Please give brief details of your reasons for wanting to move to a PRHA property
Please indicate which applies to your current housing
Your Current Accomodation
Do you have a pet?
If you rent your current home, please tell us the name and contact details of your previous landlord. Please note, PRHA may approach your landlord for a reference.
What type of accommodation do you wish to be considered for?
Employment
Housing Benefits
Where did you hear about PRHA?
Mobility and Well-Being
Further Information

By submitting your application you are agreeing to the following terms:

I conﬁrm that the information provided in this application form is true to the best of my knowledge.
I am happy for my details to be used for the purpose of referencing and for my chosen contacts to be contacted (including those outside the EEA), with personal information which has been provided in this form to allow them to verify the information about my earnings, dates of employment and previous tenancy term.
I agree to all data I submit being stored online in compliance with Arthur Online's GDPR and Privacy policies.

If you do not agree with any of these terms, do not submit your application form.