SHAC ON-LINE APPLICATION FORM
Please complete all fields
1. Your full name: Mr Miss Mrs Ms Dr
2. Employment Status: Full Time Part Time Student Temporary Unemployed
3. National Insurance Number (if known):
4. Date of Birth: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
5. Date from which housing is required: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2007 2008 2009 2010 2011 2012
6. Address of Present Residence:
7. Mailing or Forwarding Contact Address:
8. Area of Choice Preferred:
Choice 1 Choice 2
Reason you need to live in this area Reason you need to live in this area
9. Which of the following meets your housing needs?
Self Contained Housing Not Applicable 1 Bed 2 Bed 3 Bed (family) 4 Bed (family) Shared Housing Single Room Twin Room Not Applicable
Group Letting for 2 3 4 5 6 7 Not Applicable adults
10. Have you any special housing needs? No Yes
If Yes please give details
11. Have you applied to the Housing Executive or any other Housing Association, College or Agency? No Yes
12. Have you been resident in Northern Ireland for the last 7 years? No Yes
13. This question relates to your current or most recent place of residence.
Are you staying under a Formal Tenancy Informal with immediate family Informal with friends Other
Name of Landlord / Agent
Landlord / Agent's Address
14. Why do you not wish to remain at your present address?
Please read the following carefully before submitting your form:
By entering my email address and submitting this form, I declare that the answers given by me on this form are correct. I understand that incorrect or misleading statements by me on this form will result in loss of tenancy awarded to me by the Association.
I undertake to report any change in circumstances to the Association as soon as they occur. I am willing, if required, to be available, at my present address for interview in relation to this application.
I accept that an offer of a tenancy is subject to my agreement on the terms of the lease.
E-mail
Tel
FAX
Please contact me as soon as possible regarding this matter.