Applicant One
Application number *
Applicant or joint applicant? *
Please Select
Applicant
Joint Applicant
First name *
Last name *
Date of birth *
Telephone number *
Email *
Applicant Two
Applicant or joint applicant? *
Please Select
Applicant
Joint Applicant
First name *
Last name *
Date of birth *
Do you want to add a joint applicant?
Please Select
Yes
No
First name
Last name
National insurance number
Phone number
Email
Are you a current Berneslai Homes tenant?
Please Select
Yes
No
Have you been a Berneslai Homes tenant in the last 6 years?
Please Select
Yes
No
Berneslai Homes property address
What is your current tenure?
Please Select
BMBC Tenant
Housing Association Tenant
Hostel, Refuge, or B&B
Supported Housing
Leaving Hospital
Lodger
Other
Owner Occupier
Private Tenant
Please provide details
Landlords Name
Landlords Name
Landlords Name
Landlords Number
Landlords Number
Landlords Number
Landlords Address
Landlords Address
Landlords Address
Declaration
Are you related to an elected member?
Please Select
Yes
No
Please provide details
Are you related to an employee of BMBC?
Please Select
Yes
No
Please provide details
Are you related to an Employee Board Member of Berneslai Homes?
Please Select
Yes
No
Please provide details
Are you related to a Berneslai Homes employee?
Please Select
Yes
No
Please provide details
Equal Opportunities
What is your ethnic group?
Please Select
White
Mixed or Multiple Ethnic Groups
Asian or Asian British
Black, African, Caribbean, or Black British
Arab or Other Ethnic Group
Prefer Not to Say
Which of these best describes your ethnic background?
Please Select
English/Welsh/Scottish/N. Irish/British
Irish
Gypsy or Irish Traveller
Roma
Other White
Which of these best describes your ethnic background?
Please Select
White and Black Caribbean
White and Black African
White and Asian
Other Mixed
Which of these best describes your ethnic background?
Please Select
Indian
Pakistani
Bangladeshi
Chinese
Other Asian
Which of these best describes your ethnic background?
Please Select
African
Caribbean
Other Black
Which of these best describes your ethnic background?
Please Select
Arab
Any Other Ethnic Group
What is your religion?
Please Select
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Other Religion
No Religion
Prefer Not to Say
Which of the following best describes your sexual orientation?
Please Select
Heterosexual or Straight
Gay or Lesbian
Bisexual
Other Sexual Orientation
Prefer not to Say
Do you consider yourself disabled?
Please Select
Yes
No
Prefer not to Say
If we get in touch with you, do you, or anyone in your household, need us to communicate in the following ways:
Please provide details
What is your main language?
Please Select
English
Other
Please tell us which language
How well can you speak English?
Please Select
Very Well
Well
Not Well
Not at All
What is Your Sex?
Please Select
Female
Male
Prefer not to Say
Income and Assets
Are you employed?
Please Select
Yes
No
What is your households gross annual income?
Do you own property?
Please Select
Yes
No
What is your properties approximate value?
What is your outstanding mortgage amount?
Have you ever gifted a property?
Please Select
Yes
No
Please provide details
What is your current amount of savings/investments?
Please Select
£0 - £5,000
£5,000 - £10,000
£10,000 - £20,000
£20,000 - £30,000
£30,000 - £40,000
£40,000 - £50,000
£50,000+
Are you in receipt of Housing Benefit or the housing element of Universal Credit?
Please Select
No
Housing Benefit
Universal Credit Housing Element
Do you have any unspent criminal convictions? (we do not need to know about traffic offences)
Please Select
Yes
No
Please provide details
Have you ever been evicted due to anti-social behaviour?
Please Select
Yes
No
Please provide details
Have you ever been evicted due to unpaid rent?
Please Select
Yes
No
Please provide details
Do you have any outstanding arrears from a previous tenancy?
Please Select
Yes
No
Please provide details
Do you want to add anyone to your application?
Please Select
Yes
No
Do you want to remove anyone from your application?
Please Select
Yes
No
Do you want to tell us about a change of address?
Please Select
Yes
No
What is your current address?
Date moved in
What is your current tenure?
Please Select
BMBC Tenant
Housing Association Tenant
Hostel, Refuge, or B&B
Supported Housing
Leaving Hospital
Lodger
Other
Owner Occupier
Private Tenant
Please provide details
Landlords Name
Landlords Name
Landlords Name
Landlords Number
Landlords Number
Landlords Number
Landlords Address
Landlords Address
Landlords Address
Current property type
Please Select
House
Flat
Bungalow
Maisonette
Bedsit
Other
Please provide details
Number of bedrooms in your current home
Please Select
1
2
3
4
5+
Please tell us why you are still looking for rehousing after your move
What is your home's approximate value?
What is your outstanding mortgage amount?
Are you employed? *
Please Select
Yes
No
What is your household's gross annual income? *
Have you ever gifted a property? *
Please Select
Yes
No
Please provide details *
What is your current amount of savings/investments? *
Please Select
£0 - £5,000
£5,000 - £10,000
£10,000 - £20,000
£20,000 - £30,000
£30,000 - £40,000
£40,000 - £50,000
£50,000+
Are you currently in receipt of Housing Benefit or Universal Credit? *
Please Select
No
Housing Benefit
Universal Credit
Both
Are you in receipt of PIP - Personal Independence Payment? *
Please Select
Yes
No
Please select which apply to you
Your home is currently unsuitable due to physical medical needs
Please Select
Yes
No
Person with physical health need
What property could you and anybody moving with you manage in?
What sort of bathing facilities could you and other people in your household manage?
Tick all that apply
What sort of access to the property could you and other people in your household manage?
Tick all that apply
Inside the home, what can you and other people in your household manage?
Tick all that apply
Your home is currently unsuitable due to mental health, sensory, or learning disability
Please Select
Yes
No
Person with mental health, sensory, or learning disability need
To receive support
Please Select
Yes
No
Please tell us what support you receive
How often do you receive this support?
Please provide the full address and postcode of the person you are receiving support from
To give support
Please Select
Yes
No
Please provide details
Please tell us how often to provide this support
Please provide the full address and postcode of the person you are supporting
Want own home
Please Select
Yes
No
Currently homeless
Please Select
Yes
No
Please contact Housing Options on 01226 773870
Threatened with homelessness
Please Select
Yes
No
Please contact Housing Options on 01226 773870
Can't afford current home
Please Select
Yes
No
Are you currently subject to bedroom tax?
Please Select
Yes
No
What is the amount of your current rent or mortgage per month?
Are you currently in receipt of Universal Credit or Housing Benefit?
Please Select
Yes
No
What is your monthly income from employment?
Moving to take up employment
Please Select
Yes
No
Name of employer
Address of employer
Disrepair issues to home
Please Select
Yes
No
If you are a private tenant please contact BMBC’s Private Rent Sector Team on 01226 773555, or if you are a Berneslai Homes Tenant please contact the repairs hotline on 01226 787878.
Please give details of the disrepair you are experiencing
Home is overcrowded
Please Select
Yes
No
How many bedrooms is your current house?
Please Select
1
2
3
4
5+
Living room measurement
Please provide room measurements in feet and inches. For information on how to measure, please see this video .
Is there a gas fire in the living room?
Please Select
Yes
No
Any additional rooms measurement (excluding bedrooms)
Please provide room measurements in feet and inches. For information on how to measure, please see this video .
Is there a gas fire in the additional rooms?
Please Select
Yes
No
Want to downsize
Please Select
Yes
No
Please explain why you want to downsize
Domestic abuse
Please Select
Yes
No
Please contact IDAS on 03000 110 110
Please provide details
Are you currently receiving support?
Please Select
Yes
No
Please tell us who is providing support
Hate crime
Please Select
Yes
No
Please provide details
Are you currently receiving support?
Please Select
Yes
No
Please tell us who is providing support
Anti-Social Behaviour
Please Select
Yes
No
Please provide details
Are you currently receiving support?
Please Select
Yes
No
Please tell us who is providing support
Has this ASB been reported?
Please Select
Yes
No
When was this reported?
Has a case been opened?
Please Select
Yes
No
Do you require or receive support with managing money (i.e. bills, rent, unsecured debt)?
Please Select
Yes
No
If financial support is in place, please provide details
If no support is in place what support is needed?
Do you require advice relating to benefits?
Please Select
Yes
No
If benefit support is in place, please provide details
If no support is in place what support is needed?
Do you require or receive support for managing a tenancy (i.e. cooking, cleaning)
Please Select
Yes
No
If tenancy management support is in place, please provide details
If no support is in place what support is needed?
Do you require or receive support relating to drug use?
Please Select
Yes
No
If drug support is in place, please provide details
If no support is in place what support is needed?
Do you require or receive support relating to alcohol use?
Please Select
Yes
No
If alcohol support is in place, please provide details
If no support is in place what support is needed?
Do you require or receive support relating to mental health?
Please Select
Yes
No
If mental health support is in place, please provide details
If no support is in place what support is needed?
Are you able to apply for properties using our online system?
Please Select
Yes
No
Please tell us why
Do you have any unspent criminal convictions? (we do not need to know about traffic offences) *
Please Select
Yes
No
Please provide details *
Have you ever been evicted due to anti-social behaviour? *
Please Select
Yes
No
Please provide details *
Have you ever been evicted due to unpaid rent? *
Please Select
Yes
No
Please provide details *
Do you have any outstanding arrears from a previous tenancy? *
Please Select
Yes
No
Please provide details
Do you want to change your areas of choice?
Please Select
Yes
No
Please tell us which areas you would like to be rehoused
Please explain why you would like to be housed in these areas
Do you want to change the property type you want to be rehoused in?
Please Select
Yes
No
What type of property do you want?
How many bedrooms do you need?
Please Select
Bedsit
1
2
3
4
5+
Documents
By ticking the box below, I declare that I fully understand and agree with the following statements:I declare that the information I have given on this form is correct and complete. I understand that if I have not completed this form fully it may result in a delay in us acting on your request. *I confirm that all of the above information is correct