Application number Direct applicant Mutual exchange Nominations / CBL
Date form sent ......./......../........ Date form received ......./......../........ Date form input ....../......../........
Case number Area required
Housing application
Please complete and sign this form and return it to: Sanctuary Housing, Marybone House,
2 Marybone, Liverpool, L3 2BY
About you
You Joint applicant
Title Title
First name First name
Middle name(s) Middle name(s)
Surname Surname
National Insurance number National Insurance number
Telephone number Telephone number
Mobile number Mobile number
Email Email
Date of birth Date of birth
NON-MANDATORY - The information we collect below helps us to make sure that we can support you as best we can.
The information you provide in this section is voluntary and is not needed as part of your housing application.
Gender Gender
Male Male
Female Female
I prefer to use my own term I prefer to use my own term
Sexuality Sexuality
Heterosexual or Straight Heterosexual or Straight
Bisexual Bisexual
Gay or Lesbian Gay or Lesbian
Other Other
Prefer not to say Prefer not to say
Marital status Marital status
Single Co-habiting Single Co-habiting
Married Widowed Married Widowed
Civil Partnership Divorced Civil Partnership Divorced
Separated Separated
NON-MANDATORY
You Joint applicant
Ethnicity Ethnicity
White: British, Irish, Gypsy or Irish Traveller, White: British, Irish, Gypsy or Irish Traveller,
Other White Other White
Mixed/Mutiple ethnic group: White and Black Mixed/Mutiple ethnic group: White and Black
Caribbean, White and Black African, Caribbean, White and Black African,
White and Asian, Other Mixed White and Asian, Other Mixed
Asian/Asian British: Indian, Pakistani, Bangladeshi, Asian/Asian British: Indian, Pakistani, Bangladeshi,
Chinese, Other Asian Chinese, Other Asian
Black/African/Caribbean/Black British: Black/African/Caribbean/Black British:
African, Caribbean, Other Black African, Caribbean, Other Black
Other ethnic group: Arab, Any other ethnic group Other ethnic group: Arab, Any other ethnic group
Religion Religion
Christian Buddhist Hindu Christian Buddhist Hindu
Jewish Muslim Sikh Jewish Muslim Sikh
Other No Religion Other No Religion
(The categories listed above are based on those (The categories listed above are based on those
found in the 2011 Census) found in the 2011 Census)
Do you consider yourself to have a disability? Do you consider yourself to have a disability?
Yes No Prefer not to say Yes No Prefer not to say
Do you have any specific communication Do you have any specific communication
requirements, for example Braille or large requirements, for example Braille or large
print? print?
Yes No Yes No
If yes, please provide details: If yes, please provide details:
Your current circumstances
Main applicant’s current address
Date you moved in Postcode
Joint applicant’s current address (if different from above)
Type of property:
Council/Housing Association rented accommodation Owner occupier/Shared owner
Private landlord Living with family or friends
Lodger No fixed abode
Temporary accomodation Other, please provide details:
If you are living with a current Sanctuary resident, please state your relationship to them:
Do you live in a bedsit/studio?
Yes No
How many bedrooms are available for use by you and your household?
If you rent your current home, please provide landlords details:
Name
Address
Postcode
Telephone number
Email
Please list all previous addresses and landlords’ addresses over the past three years. Please include the
reason for leaving for both you and any joint applicant. Please also include any tenancies you have held
with Sanctuary in the past.
Name and address Date you Date you Reason for leaving
Property address
of landlord Moved in Moved out
Have you been asked to leave your current home? Please tick any which apply:
You have been served with a Notice of Seeking Possession or Notice to Quit by your landlord
Your home is being repossessed
Is your current accommodation inappropriate for any of the following reasons?
Relationship breakdown
Households living apart
Living in adapted property that is no longer required
Property in very poor condition, please provide details:
Other, please provide details:
Are you moving from supported housing?
Yes No
If yes, please provide details:
Are you currently in prison, if so when will you be released?
Are either you or the joint applicant currently employed?
Yes No
Why do you want to move?
In the space below, please give the reasons why you would like to move. This is an important part of the
application and will help us in banding your application. Please use our Applying for Housing leaflet to help you
complete this section.
Your household
Who is being housed with you (other than any joint applicant named above)?
Name Date of birth Gender Relationship
Are you or any member of your household pregnant?
Yes No
If yes, please provide the expected due date:
Have you or any members of your household ever had any court proceedings against any tenancy you/
they have held?
Yes No
If yes, please provide details:
Do you or any members of your household have any unspent convictions?
Yes No
If yes, please provide details:
If you/they have a Probation Officer, please provide their contact details:
Name
Contact number/address
Email
Do you have any pets/animals that you wish to be housed with you?
Yes No
If yes, please provide details:
Your housing requirements
Do you need an extra bedroom on one of the following grounds? (Please note, you will need to
provide proof)
Medical grounds Carer grounds
Do you need a property which is all one level? (Please note, you will need to provide proof)
Yes No
If yes, please provide details:
Do you need a property with lift access?
Yes No
If yes, please provide details:
What is the maximum floor level you would accept without a lift?
Do you require a property with adaptations?
Yes No
If yes, please provide details:
What type of housing would you like to be considered for? please tick all that apply
General needs housing Housing for older people (aged 55+)
In which areas would you like to be considered for housing?
1 3
2 4
Conflict of interest
Sanctuary Housing and all its subsidiaries have a policy which prevents us granting benefits to its employees,
committee members or their close relatives. Please answer the questions below to help us comply with these
provisions and assess your application properly.
Do you, or the joint applicant, work or have you worked for Sanctuary within the last 12 months?
Yes No
If yes, please provide details:
Are you, or your joint applicant, related to anyone who is a member of Sanctuary’s board committees or
forums, or a member of Sanctuary staff?
Yes No
If yes, please provide details:
Carers, advocates, support workers, friends and family members
Do you or any member of your household have a carer, social worker, key worker or support worker?
Yes No
If yes, please provide details:
If you would like someone to deal with your application on your behalf, please give their details below:
Name:
Address:
Postcode:
Telephone number:
Email:
Relationship to you:
Any other supporting information
Declaration and use of personal data
By signing this form, I/we agree to the following:
• I/we will notify Sanctuary Housing of any changes to the details provided on this form.
• I/we understand that in the event of my details being found to be untrue or inaccurate, or if I have neglected
to notify Sanctuary Housing about any changes in my circumstances, my application will be cancelled or
I may lose any tenancy offered to me. I understand that if the tenancy has commenced, Sanctuary Housing
reserves the right to take action to terminate this tenancy.
• I/we understand that my details will be held electronically.
• I/we give permission for information regarding my application to be shared with, and verified by, credit
reference agencies, statutory and voluntary bodies, including the police, in order to check the details of this
application and to provide assistance with rehousing and sustaining any tenancy that may be offered to me.
If my application is successful, I also give permission for my information to be shared with contractors who
assist with the services Sanctuary Housing provides and with private organisations, such as utility companies,
so they can provide services and contact me in respect of utility charges.
• I/we understand that Sanctuary Housing will obtain references from my previous landlords covering the last
three years.
• I/we understand that Sanctuary Housing will contact the health professionals listed above to obtain
information relating to any medical condition, or disability, in support of my application.
• I/we understand that credit checks will be carried out in order to establish my financial status.
• I/we understand that the completion of this form does not mean I will be offered accommodation.
• I/we understand that the details of this application will be used for confidential statistical purposes
Signed: (Applicant) Print name: Date:
Signed: (Joint applicant) Print name: Date:
It is very important to pay your rent on time and we want to make it as hassle-free as possible. Paying by Direct Debit is quick and easy to set
up and ensures you don’t miss a payment to us. We will ask you to set this up when you sign your tenancy agreement, so please remember to
bring your bank details with you when you.
Under the Data Protection Act 2018, we are required to explain to you why we are asking for this information about you, how we intend to use
the information you provide and whether we will share this with anyone else. Please visit www.sanctuary-housing.co.uk to read our privacy
statements.
This form can be translated into other languages, large print and Braille or recorded on to an audio CD. Please contact us for
details. If you need to speak to a Sanctuary member of staff in your own language, please contact your local office and they
will arrange an interpreter for you.
0800 131 3348 (landline) 0300 123 3511 (mobile)
contactus@sanctuary-housing.co.uk
www.sanctuary-housing.co.uk
@HelloSanctuary
Sanctuary Housing Services Limited is a subsidiary of Sanctuary Housing Association, an exempt charity.
