Step 1 of 9 11% You have expressed an interest in being considered for voluntary housing. This form is designed to provide us with information to assess the type of housing that will be best suited to your needs and to ensure you are provided support to maintain a tenancy should you require it. Please ensure that you fill out all relevant sections of the form and that the information you provide us is true and accurate. Withheld or false information may impact on your application for housing with Circle Voluntary Housing Association. Alternatively you can download, print and complete a PDF version of this form and post it back into us. Download Form. Documents you need to prepare before starting this form: We will request you to upload these later in the form process ‣ Proof of identity A recent photo of drivers’ licence, passport, national age card issued by An Garda Síochána, public services card. ‣ Accessibility report Any supporting documentation relating to a requirement for specially adapted accommodation. Section 1 - Applicant/s DetailsIs this a single or joint application?* Single Joint Applicant 1Your name:* First Last Date of birth:* DD slash MM slash YYYY Are you?* Male Female Your current address: Street Address Address Line 2 City County / State / Region Eircode Your mobile phone number:*Your email address:* Housing reference number:What is your nationality?*Is English your first language?* Yes No If not, what is your first language?* Applicant 2Joint applicants name:* First Last Date of birth:* DD slash MM slash YYYY Are you?* Male Female Relationship to first applicant:*Your current address: Street Address Address Line 2 City County / State / Region Eircode Your mobile phone number:*Your email address: Housing reference number:What is your nationality?*Is English your first language?* Yes No If not, what is your first language?*Proof of Identity (for all applicants)*Please upload a copy of drivers’ licence, passport, national age card issued by An Garda Síochána or public services card. Drop files here or Select files Accepted file types: jpg, jpeg, png, pdf, , Max. file size: 10 MB, Max. files: 4. Section 2 - Housing HistoryWe want to know about where you currently live and where you have lived to help us understand what type of accommodation best suits your needs.What is your current living situation?* Residing in Local Authority housing Residing in private rented accommodation Residing in another Housing Association property Residing in emergency accommodation/refuge How long have you been living there?*Are currently paying rent or an accommodation charge?* Yes No If Yes, how much are you paying?* Please give details of your 4 most recent addresses (starting with the most recent):Addresses might include a home you owned, a rented home, social housing or emergency accommodation. Address Type of Accommodation: From To Actions Edit Delete There are no Addresses. Add Address Maximum number of addresses reached. Have you, or any of the persons listed on this application, ever been evicted from previous housing?* Yes No If yes, please describe the circumstances relating to this:* Section 3 - AccessibilityDo you, or any of the persons who will be living with you, require accommodation that is specifically adapted for a person with restricted mobility or additional needs, based on physical or medical grounds?* Yes No Doctor's / Consultant's / Occupational Therapist's / Social Worker’s reportPlease upload a Doctor's / Consultant's / Occupational Therapist's / Social Worker’s report in support of this application. Drop files here or Select files Accepted file types: jpg, jpeg, png, pdf, , Max. file size: 7 MB, Max. files: 4. Section 4 - Household DetailsWill any children or dependants be living with you if you are allocated a home?* Yes No Who will be living with you if you are allocated a home? Name Date of birth: Relationship Current Address Actions Edit Delete There are no Dependents. Add Dependent Maximum number of dependents reached. Section 5 - Support NeedsWe want to make sure that you enjoy living in your new home and that you receive any relevant support. To do that we would like to know if you are currently receiving support, or need support in any of the following areas? Current Family Relationships Child Welfare Legal issues Income Finance Physical Health Mental/Emotional Health Alcohol Use Drug use Other areas of support Are you currently receiving support, or do you need support in any of the areas listed above?* Yes No Please choose the support needs relevant to you and your family: Support Area Nature of support currently being received: Future support needs: Actions Edit Delete There are no Support Needs. Add Support Need Maximum number of support needs reached. Are you currently receiving support from anyone or another agency (e.g. keyworker, social worker)?* Yes No Please provide us with details (including phone no.): Support Worker name: Role and Organisation: Contact Number: Actions Edit Delete There are no Support Workers. Add Support Worker Maximum number of support workers reached. Section 6 - Legal Issues/OffencesHave you or any of the persons listed on this application ever been investigated or convicted or have charges pending in respect to any criminal matter, anti-social behaviour or public order offences?* Yes No Please provide us with details of each investigation or conviction, including dates: Type of conviction/investigation: Date it occurred: Actions Edit Delete There are no Legal Issues/Offences. Add Legal Issue/Offence Maximum number of legal issues/offences reached. Section 7 - Additional InformationIf there is any other information that you feel is relevant to your application, please fill in the following section: Section 8 - Your Application AgreementPlease read the statements below carefully and check the relevant consent boxes. To the best of my knowledge, all the information that I have given on this application form is accurate. I understand that if I have knowingly given inaccurate information my application may be refused. Consent* I/we agree to the statement above.Your name:* First Middle Last Your name: First Middle Last Date* DD slash MM slash YYYY Sharing of information Circle Voluntary Housing Association is collecting this information, so we can assess the type of housing that will be best suited to your needs. To process your application, we will need to share the information you have supplied with your localauthority and other relevant services that you have identified on this form. This is to ensure you are safe in your home and to ensure we can support you to live in your home. We ask you to give consent to this. Circle Voluntary Housing Association will follow the principles of the Data Protection Act and will make sure that the information you have provided is: Used fairly and legally. Only used for the purposes for which it was collected. Adequate, relevant and not excessive. Correct and up to date. Kept only for as long as needed. Processed in accordance with a person’s rights. Stored safely. Your confidentiality is assured except when there is an issue around child safety; violence to yourself or others; the courts request a report, or you inform the worker of a criminal act you have committed or intend to commit. Consent* I agree to my information being shared by the services outlined above.Your name:* First Middle Last Your name: First Middle Last Date* DD slash MM slash YYYY Section 9 - Check and submit your applicationPlease now use the 'previous' and 'next' buttons to check through your application to make sure that everything is correct and in place. When you are ready, please click the submit button below. Thank you for taking the time to submit the form. Δ Need help or have questions about completing this form? Click here to contact us.
