Form 2 This form will take around 15 minutes to complete and cannot be saved as you go, so please leave enough time to answer all of the questions before starting. To translate or listen to any of these questions, highlight the text you want to access using your cursor, and a small box will appear giving you the option to listen or translate.Please enter the address of the property you are applying for below(Required)Section One - Household Details1.1 Please give details for yourself and any joint applicant who will share the tenancy with youLead Applicant - TitleLead Applicant - First name (s)(Required)Lead Applicant - Surname name(Required)Lead Applicant - Former nameLead Applicant - Date of birth(Required) DD slash MM slash YYYY What is your sex?(Required) Male Female Prefer not to say Other What gender do you identify with?(Required) Male Female Transgender Non-binary Prefer not to say Other Lead Applicant - Current address and postcode(Required) Street Address Address Line 2 City County Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Lead Applicant - Length of time at this address (years/months)(Required)Lead Applicant - Mobile number(Required)Lead Applicant - Landland numberLead Applicant - Work numberLead Applicant - Email(Required) Joint applicant details - if applicableJoint Applicant - TitleJoint Applicant - First name (s)Joint Applicant - Surname nameJoint Applicant - Former nameJoint applicant - Date of birth DD slash MM slash YYYY What is your sex? Male Female Prefer not to say Other What gender do you identify with? Male Female Transgender Non-binary Prefer not to say Other Joint Applicant - Current address and postcode Street Address Address Line 2 City County Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Joint Applicant - Length of time at this address (years/months)Joint Applicant - Mobile numberJoint Applicant - Work numberJoint Applicant - Email 1.2 Additional household members who will be living with you at your new address - please include their FIRST NAME, SURNAME, DATE OF BIRTH, SEX, and RELATIONSHIP to lead applicant. If there are no additional household members please add N/A and you run out of space, please use the notes section at the end of this form.(Required) If any of these people have a different address to the lead applicant, please state who and give their current address:1.3 If anyone in your household is expecting a baby, please state who and the expected date of birth:Section Two - Housing History2.1 If you are currently a tenant, please give your landlord’s details Landlord's nameLandlord's address, email address and phone numberYour current rent (£week/month):If you have a Housing Officer, please given their name and phone no./email address:2.2. If you have lived at your current address for less than 3 years, please list previous addresses, dates you lived there, whether it was owned or rented by you and if rented, provide the name, address and telephone number of the landlord. If you run out of space please use the notes section at the end of this form.Do you owe your current or a previous landlord any rent?(Required) Yes No If YES, how much rent do you owe your current and/or a previous landlord?2.3 Do you or your partner own/part-own any property in any country (even if you do not live there)?(Required) Yes No If yes, then we will ask for more information about this because it may affect whether we can offer you a tenancy2.4 Have you ever applied to or been housed by CHS Group before?(Required) Yes No If YES, please give If details:Section Three - Health and Support Needs3.1 Do you or anyone else in your household have a medical condition, mental health issue or physical disability?(Required) Yes No If YES, please tell us who it affects and anything we need to know to provide you with a good service3.2 Do you or any member of your household need any special equipment, aids or adaptations to live in your new home? (e.g. wheelchair access, grab rails, level-access shower, through floor lift).(Required) Yes No If YES, please give details3.3 Please give the name, email address and phone number of any professional who is or will be providing you with support and/or treatment in relation to any health, disability or support needs e.g. G.P., Occupational Therapist, Mental Health Worker, Social Worker, Probation Officer:At the end of this form, you will be asked to give your consent for CHS Group to contact relevant professionals for more information.Section Four - Additional Information4.1 Please list any pets you would like to bring with you to your new home: Number and type of pet(s):Please note that you need CHS Group’s permission to keep some types of pet, if you are offered a property your Housing Officer will advise you about this and you might need to apply for permission.4.2 Please list any cars, trailers, caravans or other motor vehicles that you would like to keep at your home:4.3 In the last 2 years, have you been accused of or experienced any form of anti-social behaviour in or near to your home?(Required) Yes No If YES, please give details of the type(s) of behaviour(s) and any action taken by relevant agencies e.g. the police or your landlord:4.4 Please give details of your next of kin including name, relationship to you, next of kin address and their telephone number. You do not have to provide this information, but it could be useful, especially for applications for supported housing or older people’s services.Section Five - Declarations5.1 You and any joint applicant must declare any connections to CHS Group.Do you work or have you worked for CHS Group?(Required) Yes No Are you related to someone who works / has worked for CHS Group?(Required) Yes No Are you or have you been a CHS Group Board Member?(Required) Yes No Are you a relative of a current or previous CHS Group Board Member?(Required) Yes No If you have answered YES to any of these questions, please give details:Section Six - Customer questionnaireWe would like to know more about you and any partner you may have. We will use this information to help us make sure that we treat all of our customers fairly, and to develop services that meet your needs. Some of the information you give us will also be used for statistical and monitoring purposes. If you do not wish to complete any section of the questionnaire you are free to leave it blank. Please refer to CHS Group’s Privacy Notice for more information on how we handle this data 6.1 It would help us to ensure that our equality and diversity policy is carried out if you would answer this question about ethnic origin. It will not affect your application. Please tick the box that best describes your ethnic origin. Please also tick one box for all other people to be housed. These numbers relate to those in Question 1.Lead applicant ethnicity(Required)Please click to select from dropdownIndiaPakistaniBangladeshiChineseOther AsianBritish WhiteIrish WhiteIrish TravellerRoma GypsyOther whiteWhite & Black CaribbeanWhite & Black AfricanWhite & AsianOther MixedCaribbeanAfricanOther BlackOther Ethnic GroupPrefer not to sayJoint applicant ethnicityPlease click to select from dropdownIndiaPakistaniBangladeshiChineseOther AsianBritish WhiteIrish WhiteIrish TravellerRoma GypsyOther whiteWhite & Black CaribbeanWhite & Black AfricanWhite & AsianOther MixedCaribbeanAfricanOther BlackOther Ethnic GroupPrefer not to sayAdditional Person 1 ethnicityPlease click to select from dropdownIndiaPakistaniBangladeshiChineseOther AsianBritish WhiteIrish WhiteIrish TravellerRoma GypsyOther whiteWhite & Black CaribbeanWhite & Black AfricanWhite & AsianOther MixedCaribbeanAfricanOther BlackOther Ethnic GroupPrefer not to sayAdditional Person 2 ethnicityPlease click to select from dropdownIndiaPakistaniBangladeshiChineseOther AsianBritish WhiteIrish WhiteIrish TravellerRoma GypsyOther whiteWhite & Black CaribbeanWhite & Black AfricanWhite & AsianOther MixedCaribbeanAfricanOther BlackOther Ethnic GroupPrefer not to sayAdditional Person 3 ethnicityPlease click to select from dropdownIndiaPakistaniBangladeshiChineseOther AsianBritish WhiteIrish WhiteIrish TravellerRoma GypsyOther whiteWhite & Black CaribbeanWhite & Black AfricanWhite & AsianOther MixedCaribbeanAfricanOther BlackOther Ethnic GroupPrefer not to sayAdditional Person 4 ethnicityPlease click to select from dropdownIndiaPakistaniBangladeshiChineseOther AsianBritish WhiteIrish WhiteIrish TravellerRoma GypsyOther whiteWhite & Black CaribbeanWhite & Black AfricanWhite & AsianOther MixedCaribbeanAfricanOther BlackOther Ethnic GroupPrefer not to say6.2 If you think it would be helpful for CHS to know your nationality (e.g. to take into account translation requirements) please state below. It will not affect your application. Please state your nationality for both lead applicant and joint applicantSECTION SEVEN - MUST BE SIGNED BY YOU AND ANY JOINT APPLICANT7.1 If I apply for housing with another social landlord in future, I understand that CHS Group may be asked to give a reference about any tenancy I have held with them. I am aware that the reference would include details of rent payments and any breaches of the tenancy agreement, including anti-social behaviour. I agree that CHS group can share such information with other social landlords for this purpose. 7.2 I agree to CHS approaching other relevant third parties (e.g. landlords, employers, G.P. Social Worker, Occupational Therapist etc.) regarding my application and give my permission for those third parties to share relevant personal information with the CHS Group for the purposes of determining my application for housing.DATA PROTECTION STATEMENTDATA PROTECTION STATEMENT In order to assess your housing application and help us deliver efficient services, we need to collect relevant personal information. We comply with data protection legislation when collating and managing personal data. This means that your personal data will be processed in accordance with the law and will be kept safe and secure and for no longer than is necessary. If you have any questions or queries regarding data protection, please e-mail dataprotection@chsgroup.org.uk You can see CHS Group’s Privacy Notice in full at the CHS Group website www.chsgroup.org.uk You are advised that in order to assist in the prevention and detection of fraud your personal information may be used for the purpose of data matching by the CHS Group and other public bodies under the National Fraud Initiative. We may also use it for prevention and detection of fraud. Lead applicant name/electronic signature(Required)Date(Required)Lead Applicant Consent(Required) By ticking this box I confirm that I understand and agree to all of the aboveJoint applicant name/electronic signatureDateJoint Applicant Consent By ticking this box I confirm that I understand and agree to all of the aboveNotes: please use this space to tell us the reason you are looking for a new home and anything else you think is relevant to your application:Please upload photographic ID for the applicant/joint applicant belowAttach documentsMax. file size: 50 MB.
