ࡱ>    #` pbjbjmm .pFQFQFQFQbQr"U"U"U"U"UVVVkkkk5lo"r$shuRFrIYUVIYIYFr"U"U[rYYYIY:"U"UkYIYkYYY"UU W|%EFQY:YGZqr0rYGvY4GvYGvYLVVYCWlWVVVFrFrY VVVrIYIYIYIYDMFQFQ When completed this form should be returned to: CONFIDENTIAL YORK HOUSING ASSOCIATION LTD 2 Alpha Court, Monks Cross Drive YORK YO32 9WN Tel: 01904 636061 APPLICATION FOR SHARED HOUSING IN YORK 1NAME OF APPLICANT AND DETAILSSURNAMEOTHER NAMESSEX M or FDATE OF BIRTH2HAVE YOU ANY PETS OR OTHER ANIMALS? YES/NO. If Yes, please give details: 3ADDRESS AT WHICH YOU ARE LIVING NOWTel No:4ADDRESS FOR CORRESPONDENCE (if different from where you live)Tel No:5HOW LONG HAVE YOU LIVED AT YOUR PRESENT ADDRESS?6RELATIONSHIP TO STAFF/COMMITTEE MEMBERS OF THE ASSOCIATIONWe are forbidden by law to grant benefits (including tenancies) to employees or Committee Members of the Association, or to their close relatives. In order to assist us in complying with law will you please provide the following information:Are you an employee or committee member of the Association or a relative on one (by blood or marriage)? (Please state YES or NO) If you have answered YES to this question please give details  7HAVE YOU EVER HAD A TENANCY WITH YORK HOUSING ASSOCIATION? PLEASE GIVE DETAILS OF YOUR PRESENT ACCOMMODATION 8ARE YOU (please tick)9IS YOUR PRESENT ACCOMMODATION (please tick)TenantTerraced HouseLodgerDetached HouseOwner/BuyingSemi-Detached HouseLiving with relativesBungalowLiving with friends)Flat (which floor?.....)Other (please specify)Bedsit (which floor?.....)Other (please specify) 10FACILITIES (please tick)11IF YOU SHARE ANY OF YOUR ACCOMMODATION WITH ANOTHER Separate KitchenHOUSEHOLD PLEASE GIVE DETAILS:Living RoomBathroomNo of BedroomsInside WCHot Water SupplyCentral Heating 12IF YOU ARE A TENANT/LODGER PLEASE STATEName and address of your landlordWeekly Rent: 13IF YOU ARE BUYING/OWNER PLEASE STATEMonthly Mortgage RepaymentsMortgage OutstandingEst Value of Property 14PLEASE STATE WHY YOUR PRESENT ACCOMMODATION IS UNSATISFACTORY OR UNSUITABLE FOR YOU, AND/OR WHY YOU HAVE TO LEAVE 15Do you have any physical disability or medical condition which would affect your choice of accommodation, or would require any adaptations to be undertaken to your accommodation? If so please give details: 16PLEASE GIVE THE FOLLOWING INFORMATION ABOUT YOUR INCOME, EMPLOYMENT AND SAVINGSSelf Occupation Name & Address of Employer Salary Wage (topline - before deductions) per week/ per month Other Income including benefits, pensions etc (please specify)  17Please state, as fully as possible, the reasons for your application, and any additional information you wish to give in support of your application. (please continue on a separate sheet if necessary) STATEMENT/SIGNATURE I certify that the information given in this application is a true statement of my present circumstances Signed..........................................................................................................Date.........................  ETHNIC ORIGIN It is the policy of the Association to ensure that all applicants receive equal treatment regardless of their race, colour, ethnic or national origins. 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