Application for the Welfare Fund – Tenant Enquiry Form
SECTION 1: About the applicant(s)
Full name:
NI No.:
Full postal address:
Date of birth:
Post Code:
Telephone:
Email:
DD/MM/YYYY
Mobile:
Are you the tenant?
If no, who will be the principal beneficiary
Explain why the tenant is not applying:
Yes / No *
Is the request for a service or item for the applicant?
SECTION 2: Household Details
2.1 Please list the name, age and relationship to the tenant of anyone else who will benefit:
Name
DOB
Address
Beneficiary (Y/N)
Estuary Housing Association | Centre Place
SECTION 3: About applicant’s needs
3.1 Describe the service or item that is requested. Please tell us why it is needed and why the
emergency has arisen at this time?
SECTION 4: Declaration
4.1 The details on this form are accurate.
Signatures: (This should be signed by the tenant or both tenants if it is a joint tenancy)
……………………………………….
…………………………..
……………………………
……………………………………….
Full name:
…………………………….
Signature:
……………………………
Date:
Please return your completed form to:
Via post to:
Housing Officer
Estuary Housing Association
Centre Place
Email: [email protected]
Estuary Housing Association | Centre Place
Equality and Diversity Monitoring Form
Estuary Housing Association is committed to ensuring that we do not discriminate against any person
due to their ethnic origin faith, gender, age, sexual orientation or disability. We collect the following
information to enable us to make sure that we meet the needs of all of our residents. All information
collected will be stored and utilised in line with the Data Protection Act 1998. This information will not
be shared with any other agency or organisation.
1)
Are your day-to-day activities limited because of a health problem or disability which has
lasted, or is expected to last, at least 12 months? Include problems related to old age. If no,
please go to question 3.
Applicant / Tenant
Joint Tenant (If applicable)
Yes, limited a lot
Yes, limited a little
No
Prefer not to say
2)
If you answered yes to the above, what is the nature of your illness / disability? Please tick all
that apply.
Applicant / Tenant
Joint Tenant (If applicable)
Physical / mobility impairment, such
as difficulty with moving your arms,
or mobility issues which require you
to use a wheelchair or crutches
Visual impairment, such as being
blind or having serious visual
impairment
Hearing impairment, such as being
blind or having serious hearing
impairment
Mental health condition, such as
depression or schizophrenia
Learning disability
Longstanding illness or health
condition, such as cancer, HIV,
diabetes, chronic heart disease or
epilepsy
Drug / alcohol and/or other additional
problems
Developmental difficulties such as
autistic spectrum disorder (ASD),
dyslexia or dyspraxia
Learning difficulties including
problems with literacy and / or
numeracy
Estuary Housing Association | Centre Place
3)
Please tell us your religion
Applicant / Tenant
Joint Tenant (If applicable)
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Any other religion (Please specify)
Prefer not to say
4)
Which of the following best describes you?
White
English / Welsh / Scottish / Northern
Irish / British
Irish
Gypsy
Irish Traveller
Any other white background
Applicant / Tenant
Joint Tenant (If applicable)
Mixed / Multiple ethnic groups
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple ethnic
background
Asian / Asian British
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
Black / African Caribbean / Black British
African
Caribbean
Any other Black / African / Caribbean
background
Other Ethnic Group
Arab
Any other ethnic group
Prefer not to say
Estuary Housing Association | Centre Place
5)
How would you describe your sexual orientation?
Applicant / Tenant
Joint Tenant (If applicable)
Heterosexual
Bisexual
Gay man
Lesbian / gay woman
Don’t know
Prefer not to say
6)
Do you consider yourself to be transgender?
Applicant / Tenant
Joint Tenant (If applicable)
Yes
No
Prefer not to say
7)
Which of the following best describes your current relationship status?
Applicant / Tenant
Joint Tenant (If applicable)
Married
Widowed
Divorced
Separated
Civil Partnership
Living together but not married
Single
Thank you for completing the monitoring form.
Estuary Housing Association | Centre Place