PLEASE RETURN THIS FORM TO:
Bahay Kubo Housing Association
129 St.Johns Way
London N19 3RQ
Tel/Fax: 020 7281 4477
emma@bahaykubo.org.uk
www.bahaykubo.org.uk
HOUSING APPLICATION FORM
IMPORTANT
Please complete this form as fully as possible. It is designed to obtain
information about you, your family and your present living conditions. If you
want help filling in this form, please contact the office. Any information you
give will be treated in strictest confidence. Please note that completing this
form does not guarantee that you will be offered accommodation.
PERSONAL DETAILS
Mr/Mrs/Ms
_________________
Surname
Present address
__________________
Other names
_______________ Tel.No. (Home) ____________
_______________ Tel. No (Work) ____________
_______________
Postcode _______
HOUSING SITUATION
1. Are you in danger of losing your current home?
Yes
No
If yes, please give details.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Bahay Kubo 2012
2. Is your current home unsatisfactory in any way?
Yes
No
If yes, please give details.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
3. Do you suffer from any medical, social or other problem that makes it difficult for you
to find accommodation?
Yes
No
If yes, please give details.
______________________________________________________________________
______________________________________________________________________
_________________________________________________
3. Which of the following best describes the tenure of your accommodation?
4. In which borough are you located?
Camden
Kensington&Chelsea
Islington
Haringey
Ealing
Westminster
Hammersmith&Fulham
Newham
Other (please specify)
Permanent accommodation
Assured shortlife accommodation
Unassured temporary
accommodation
Living with employer
Living with friends or relatives
Other (please specify) ____________
4. Do you share facilities with other tenants?
5. If you do share facilities, which ones? (tick all that apply)
Kitchen
Bath
Toilet
Sitting room
Garden
Other (please specify)
__________________
______________
5. Have you applied to the Council for housing?
Date of application ____________________
Yes
No
Waiting list number ____________
6. Please give details of your previous addresses in the past five years.
Address
Date moved in Date left
(a) ________________________________
___/___/___
___/___/___
(b) ________________________________
___/___/___
___/___/___
(c) ________________________________
___/___/___
___/___/___
(d) ________________________________
___/___/___
___/___/___
(e) ________________________________
___/___/___
___/___/___
(f) _________________________________
___/___/___
___/___/___
6. With how many other people do you share these facilities?
One
Two
Three
Four
Five
More than five
7. How often do you pay rent?
Weekly
Quarterly
Every two weeks
Yearly
Monthly
Other (please specfiy)
_________________
8. In which band is your weekly rent?
PRESENT ACCOMMODATION
1. Which of the following best describes your present situation?
Council tenant
Housing association tenant
Worker living with employer
Homeowner
Tenant of a private landlord
Other (please specify)
__________________
I do not pay rent
Less than 50
Between 50 and 75
Between 75 & 100
Between 101 & 150
Between 151 and 200
More than 200
PREFERENCES
1. In which areas of London would you prefer to live?
2. What type of accommodation do you live in?
House
Flat
Self-contained bedsit
Room to yourself but in a
shared house
Room shared with
another person
Other (please specify)
_________________
Camden
Kensington&Chelsea
Islington
Haringey
Ealing
Westminster
Hammersmith&Fulham
Newham
Other(pls specify)
___________________
Please state reason/s for this preference.
________________________________________________________________
________________________________________________________________
________________________________________________________________
4. Do you access state benefits?
Yes
5. Which of the following benefits do you receive?
Income support
Housing benefit
No
Family Credit
Child benefit
Other (pls specify) ______________
2. How much space do you require?
6. In which band is your net weekly income?
One bedroom
Two bedrooms
Three bedrooms
Four bedrooms
Five bedrooms
More than five
3. If you have any other requirements that should be taken into account if an offer of
accommodation is made, please explain below.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
HOUSEHOLD DETAILS
1. Please give details of yourself and all those with whom you are applying to be
housed.
Name
Date of birth
Sex
Relatnship to applicant
(a) ____________________
___/___/___
M/F
________________
(b) ____________________
___/___/___
M/F
________________
(c) ____________________
___/___/___
M/F
________________
(d) ____________________
___/___/___
M/F
________________
(e) ____________________
___/___/___
M/F
________________
(f) ____________________
___/___/___
M/F
________________
(g) ____________________
___/___/___
M/F
________________
INCOME
Less than 100
Between 151 and 200
Between 251 and 300
Between 101 and 150
Between 201 and 250
More than 300
7. If there is another wage-earner in your household, how much additional
Income does s/he bring in weekly?
No other wage-earner
Between 101 and 150
Between 201 and 250
More than 300
Less than 100
Between 151 and 200
Between 251 and 300
8. Please us this space to give any additional information that may help
your appication.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
FOR OFFICE USE ONLY
DATE RECEIVED: ________/_________/_________
1. Do you have any paid work at the moment?
2. If you are working, is your job
Full time
Part time
3. What is the nature of your work?
Domestic worker
Nursing and auxiliary
Manufacturing
Civil service
Professional/managerial
Yes
No
REFERRAL AGENCY:
___________________________
REFERENCE NO.
___________________________
DEALT BY:
___________________________
COMMENTS:
___________________________
___________________________
___________________________
Seasonal
Catering
Retail and services
Building and construction
Administrative/clerical
Arts & theatre
