APPLICATION FOR TEMPORARY ACCOMMODATION                                                       OFFICE USE
                     Applicants requiring permanent housing should also complete the application form for
                           housing through the Northern Ireland Common Tenant Selection Scheme                    ONLY

                               Head Office: 33 May Street, Belfast BT1 4NA, Northern Ireland
Personal Details                                                                                                  REF NO.
First Name:                                                   Surname:
Title: (Mr/Mrs/Miss/Dr/Other                                      )          Date of Birth:
MALE / FEMALE                                   Marital Status: Single / Married / Separated / Divorced

National Insurance No./ PPS No:                                                                                 ASSESSMENT

If you do not have a National Insurance Number/PPS Number please state reason:
If National Insurance Number/PPS Number not provided, please complete the following:                            ACKNOWLEDGED

Passport Number:                                            Driving Licence Number:

Address                                                                                                          REVISIONS &
Address of current residence                                  Home/Permanent Address                            AMENDMENTS

Tel:                                                          Tel:
Mobile:                                                       Email:
                              Work Tel (If applicable):


Please highlight your current tenure:
    Formal Tenancy                                                    Living with family

        Living with friends                                           Hostel

        Other (specify)

If you currently have a formal tenancy, please provide details of your landlord.
Tel:                                                         Email:

Accommodation Information
Address or Area Preferred:
       st                                                              nd
    1 Choice                                                          2     Choice

Which of the following meets your housing needs?

A           Self Contained Housing      1 bed             2 bed             3 bed (family)    4 bed (family)

B                 Shared Housing         Single Room                            Twin Room

                   Joint Tenancy of accommodation with                        bedrooms
If this is a joint application, please list the names of the people you would like to share with. Please note
that all applicants for a joint tenancy must complete a separate application form.

Date from which housing is required:
Economic Status:
Employed Full-time                       Student Full-time                     On State Benefits
                                                                               Please state which benefit(s) you receive:
Employed Part-time                       Student Part-time                     Disability Living Allowance

Name and address of employer             Name and address of place of study    Job Seekers Allowance

                                                                               Income Support

                                                                               Other (specify)

                                         Student Number:

                                                                                  Social Security Office:

Have you any special housing requirements?
  YES                    NO                If ‘yes’ please provide details:

Have you applied to NIHE, other housing association, college or private landlord?
  YES                    NO                If ‘yes’ please provide details:

  Landlord                     Details

Please provide details of all changes of address over the last 5 years:


  Telephone Number

  Dates of occupancy

  Address of accommodation

  Reason for leaving
Please continue on additional sheet if necessary.

Why do you have to leave your current accommodation?
  Distance from college/work                                        Overcrowding

  Poor condition                                                    Dispute with other occupants

  Intimidation/harassment                                           Eviction by landlord

  Relationship breakdown                                            End of fixed term tenancy

  Other (specify)

  Please provide details:
Have you ever been in breach of the following tenancy conditions in your previous accommodation?

                                                Yes                   No

Anti-social behaviour

Other breaches of tenancy conditions

If ‘yes’ please provide details (including the outcome):

Failure to disclose all relevant information may result in your tenancy being terminated.

Do you currently receive support from the following?
                                   Yes            No                                                  Yes           No
Probation Officer                                               Community Psychiatric Nurse

Social Worker                                                   Other

If ‘yes’ please provide details:




Telephone No:

Level of support:

Please provide details of two referees who are willing to support your application for accommodation. These
should either be current/previous landlords, employers or college tutors and should not be friends or relatives.

Name:                                                           Name:
Address:                                                        Address:

Tel. No.:                                                       Tel. No.:
Relationship:                                                   Relationship:

Statement of Applicant
I declare that the answers given by me on this form are correct. I understand that incorrect or misleading statements by
me on this application may result in loss of any tenancy awarded to me by the Association. I undertake to report any
changes 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 consent to the Association disclosing information held on this application to third parties in relation to my application. I
also consent to other agencies giving information to SHAC Housing Association in relation to my application for
accommodation and any tenancy that may result from it.
I accept that an offer of a tenancy is subject to any agreement of the terms of lease.
Please state how you first heard about SHAC Housing Association:

NIHE/Housing Association                                   SHAC tenant

Private landlord                                           Word of mouth

Internet                                                   Social Services

Newspapers/Magazines                                       School/University

Other (specify)

                                             Data Protection Act

   SHAC Housing Association is the data controller within the terms of the Data Protection Act 1998, and all
information gathered will be stored and processed within the principles laid out within the Act. The information
    is required for the general purposes of providing a housing service. A more detailed explanation of the
    purposes for which data is processed, and rights of subject access, is contained within SHAC Housing
                                Association’s Privacy Policy, available on request.

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