Kettering application form

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Your Details

Your full name *

Date of birth *

Please describe your gender *

What is your nationality? *

How did you find out about us? *

Your contact details

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 Single room in a shared flat Ensuite room in a shared flat One-bed flat (limited availability) Family home (limited availability) 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

Privacy & Cookies
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