CONFIDENTIAL by leader6

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									     CONFIDENTIAL                                                 REGISTERED CHARITY NO. 213128


                                    The Queen’s Nursing Institute
                            3 Albemarle Way, Clerkenwell, London EC1V 4RQ
                             Telephone: 020 7490 4227 Fax: 020 7490 1269
Your Details
Surname                                              Forenames

Address

Post Code:                                   Telephone:
Married / Civil Partnership / Single / Widowed / Divorced / Separated (please indicate)

Date of Birth                                         If married or widowed MAIDEN NAME

Are you registered disabled?                          Are you registered blind?
YES              NO               APPLIED             YES               NO                APPLIED

How did you hear about the Queen’s Nursing Institute?


Qualifications:                       Registration/Enrolment No.              Date obtained
SRN/RGN/RN
SEN/EN
SCM/RM
QN
DNC
HV/RHV
Other (please state)



Brief Employment History
Dates                                 Post Held                               Employer




Date of Last Employment               Reason for leaving (retirement, ill health etc)




Particulars of family/dependents living at home or contributing to household costs
Name                      Date of Birth      Relationship             Payment to household




                                                                                                    1
Do you live in a nursing or residential home? (please specify)

Details of your property: (house, bungalow, maisonette, flat, mobile home etc)

Conditions of tenure (Owner/occupier, Leasehold, Rented – Council/Private etc)

Do you live alone or share accommodation? If shared, with whom?


Please give a brief statement about your health. Continue on separate sheet if necessary (We may ask for a
medical statement or certificate from your doctor.)




Have you applied to other charities?

Date                                      Name of Charity                  Outcome




Details of Capital Resources

*Bank Balances                              Current £                    Deposit £
(Please send copy of latest
statements)
Building Society Account(s)



Investments (list)



Any other assets (list)




                                                                                                             2
Details of INCOME
                                        Amount          Paid Weekly, Monthly,   Office Use Only
                                        £               Quarterly, Annually
Own earnings/income (after tax)
Partner’s earnings/income (after tax)
Own State Retirement Pension
Partner’s State Retirement Pension
Own Employment Pension
Partner’s Employment Pension
Pension Tax Credit
Working Tax credit
Child Benefit
Attendance Allowance
Job Seekers Allowance
Disability Living Allowance
Incapacity Benefit
Carers Allowance
Family Income Supplement
Income Support
Housing Benefit
Council Tax Benefit
Mobility Allowance
Annuities / Regular Grants and income
from other sources

Dividends / Income / Rents
Any other income (Specify)


TOTAL



If you are in receipt of any Social Security Benefits, please enclose a copy of the Department of
Work and Pensions letter showing amounts being received. Please also give the address and
telephone number of the office dealing with your benefits.




                                                                                                    3
Details of EXPENDITURE
  Please note that unessential expenditure will not be taken into consideration when assessing an
                                            application
                                  Amount        Paid Weekly,          Arrears      Office use only
                                                Monthly, Quarterly,
                                  £             Annually              £
Mortgage or Rent
Mortgage insurance
Ground charges /Maintenance
charges
Nursing/Residential Home Fee
Council Tax
Food
Gas*
Electricity *please send copy
of latest gas or electricity bill
Telephone
Water Rates
Car Insurance
Car Tax
Household/Building Insurance
Television
Nurse Registration Fee
Other (please specify)

TOTAL
Reason for application and details of help required. Continue on separate sheet if necessary




Estimated costs (please enclose estimates of quotes)

        I hereby certify that the information contained within this document is a true record of my current
         situation.
        I understand that all information provided by myself or someone acting on my behalf will form a
         manual and computer file both of which are registered under the Data Protection Act.
        For verification purposes I understand that The Queen’s Nursing Institute may contact the
         Department of Work and Pensions, NMC, Local Authorities or my GP to confirm information stated
         on this form. In some instances the QNI may also request that a letter of referral be supplied to
         support the application.
        Unless an objection is supplied in writing, information contained within this form may be shared with
         other charities in order to try to secure the help I require, and to protect the funds of the QNI.

Your Signature
                                          Date
If the form has been completed by someone other than the beneficiary, please sign below stating your
name and relationship to the beneficiary.

Signed                                 Name                                    Relationship



From time to time the QNI uses details of applications in completely anonymised form for general fundraising purposes and to continue    
our welfare work. All names and personal details are changed to ensure complete anonymity. Please tick box if you do not wish for your
application to be used in this way.
                                                                                                                                             4
                                   Equality Monitoring Form

                                         CONFIDENTIAL

This form is used to gather information for the purposes of monitoring adherence to our equal
opportunities policy only. Information will not be used for any other purpose.




                                 Personal Data

Please indicate your age group
 16-18 19-20 21-24 25-59          60+
                                        Female            Male
Declined to say                         Declined to say
Disability
Do you consider yourself
                            YES / NO Declined to say
to have some disability?
Ethnicity
Please indicate which ethnic group you belong to
White                                   Mixed
British                                 White and Black Caribbean
Irish                                   White and Black African
Any other white background              White and Asian
                                        Any other mixed background
Asian or Asian British                  Black or Black British
Indian                                  Caribbean
Pakistani                               African
Bangladeshi                             Any other Black background
Any other Asian background
Chinese or other ethnic
                                        Any other
group
Declined to say




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