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Basingstoke, Hampshire
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Basingstoke - application
Basingstoke application form
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Your Details
Your full name
*
Date of birth
*
Please describe your gender
*
Please Select
Female
Male
Prefer to self-describe
Prefer not to say
What is your nationality?
*
How did you find out about us?
*
Please Select
Through my university
Through my employer
Through a recruiter/ staff agency
i.e. Google, Bing, etc.
Hospital staff handbook
Hospital staff app
Your contact details
Email
Please confirm your email address in the relevant field
Phone number
*
Please provide your telephone number in the relevant field
Current address
*
Please confirm your current address in the relevant field
Identification
National Insurance Number
*
Passport number
*
All applications for accommodation (over 28 days) will need a Right To Rent compliance check, as required by the Immigration Act 2014. Optivo works with NSL Checking to complete these checks. Once we have reviewed your application we will use your email address and/or mobile number to register your enquiry with NSL Checking, who will contact you directly. For more information go to: http://optivo.nsl.co.uk
Accommodation requirements
What type of accommodation would you like to rent from us?
*
Any
Ensuite room in a shared flat
Patient Relative accommodation
Date I would like to move into my accommodation
*
Date I would like to move out of my accommodation
*
Do you require car parking?
*
Yes
No
Note: car parking availability can be limited and some schemes operate a waiting list or have none. Let us know your requirements and we will advise you if we can assist.
Please advise us how you intend to pay for your rent
*
To ensure we meet our Housing Association charitable aims we will need to know about how you will be able to pay the rent for your new accommodation.
Safety
Please confirm if any of the following apply to you
Mobilty issues e.g. crutches/wheelchair/ walking stick user etc
Cognitive Impairments e.g. medical issues that may impact your memory, thinking or decision making
Sensory Issues e.g. blind/impaired vision or hard of hearing
I have no mobility issues, cognitive impairments or sensory issues
In the event of an emergency evacuation, we're required to know if you have any mobility issues, sensory issues or cognitive impairments that may prevent you from self-evacuating. Please tick any that apply:
Keyworker eligibility status
Please confirm which applies to you
*
I'm a Nursing or Midwifery student on a placement
I'm a Medical student on a placement
I have been offered a job by the NHS
I'm a Keyworker - I already work for the NHS
I'm a Patient relative (Basingstoke and Kettering only)
I'm a Keyworker (not working for the NHS)
Employers name
If you're a keyworker, not working for the NHS, please tell us who you work for
Job title
Department
Contract type
Confirmation statement
Please tick the box if you accept our terms and conditions
*
I agree to the above terms and conditions
I confirm that the information given on this form is correct to the best of my knowledge, and that no relevant information has been withheld. If I am found to have withheld information now or in the future relating to my application for accommodation, Southern Housing reserves the right to withdraw any offer made or may request that you vacate the accommodation. I understand that the information provided will be treated in the strictest confidence and according to Southenern Housing’s Privacy Notice
Consent for storing submitted data
*
Yes, I give permission to store and process my data
Submit