Long Stay Application Form - Spectrum Housing Group

ACCOMMODATION NOMINATION FORMALL APPLICANTS TO COMPLETE IN BLOCK CAPITALS - PART AWhich location will you be employed at?.............................................................................Surname (as on passport)……………………………..……..First Name……………………………………………………..Title………… Marital status……………………… Sex………… D.O.B…………Department………………………………Job Title/Grade………………………….Contact phone number……………………………Mobile……………………………….Email address………………………………………Contact address……………………………………………………………………………….…………………………………………………………………………………………………..Accommodation requiredFrom……………………………….(first night)To…………………………………..(last night)Accommodation preferred* (Single Shared/Married/Family)If Family please provide details of family membersName Relationship M/F Date of Birth Ethnicticity Religion*If single sex accommodation required please advise at time of bookingDo you Smoke* (Y/N)……………. * This is a non-smoking site - With effect from 1stJanuary 2012 no smoking allowed in shared accommodation or accommodation withshared accessSpecial requirements i.e unable to climb stairs, single sex flat required………………..Car make and registration……………….. ………………………………………………..FOR PARKING AT ISLE OF WIGHT SITES PLEASE CONTACT CAR PARK SECURITYAT THE TRUST – 01983 534500

FOR ALL RESIDENTS TO COMPLETE: PART BYou may feel some of these questions are not directly relevant to the allocation of accommodation;however this information may be kept and used to help the Association to monitor and developservices that ensure full equality of opportunity.We recommend that you read the leaflet “About the information we hold about you” and youconsent to the processing of information as described in that leaflet. If you require a copy pleasecontact 08007837837 or download from our website www.spectrumhousing.co.ukAs a resident how do you wish us to contact you?Preferred contact method-Email, Phone Post Visit(Please circle one)Preferred contact time(Please delete the hours not suitable)Before 8am Between 8am-1pm Between 1pm-5pm After 5pmEQUALITY AND DIVERSITY1) How would you describe yourself? (Please tick one box)White: British IrishAny other White backgroundAsian or Asian British: Bangladeshi IndianPakistaniAny other Asian backgroundBlack or Black British: African CaribbeanAny other BlackbackgroundChinese:Mixed: White and Asian White and Black African White and Black Caribbean Any other mixed backgroundAny other Ethnic Group: Please specify2) Do you consider yourself to have a disability? Yes / NoIf yes, what is the nature of your disability?Physical Impairment Wheelchair User Mobility Impairment OtherSensory Impairment Sight HearingOtherMental Impairment Learning disability Are you registereddisabled?OtherYes / No

3) Please indicate the main religion of your household:Baha’i Hinduism Scientology Buddhism Islam Shinto Christian Jainism Sikhism Confucianism Judaism Zoroastrian/Parsi Daoism Rastafarianism Other 4) Sexual Orientation (Please circle)Opposite sex Both sexes Same sex Not specified Question refusedHow did you hear about WCHA accommodation (this field must be completed)01 WCHA Poster 02 WCHA StaticBanner/Leaflet Stand03 Trust Dept/Ward 04 Friend 05 Existing Residents06 New Starter 07 WCHA Internet Site 08 Trust Internet Site 09 Trust Intranet(Internal) Site10 Trust StaffMagazine11 Site AdvertisingHoarding12 Bounty Scheme 13 WCHAPromotion/Open Days14 Other (please state)……………………………………………..Signature……………………………….DatePart CFull Time/Part Time/Student/Locum/Casual/Bank………………………………………………………………...National Insurance number…………………………….Passport number………………………………………….Next of kin details………………………………………………………………………. (Name)………………………………………………………………………………. (Address)…………………………… (Tel No) ……………………………………. (Relationship)If payment made by third party: Name…………………………………………..Address……………………………………………………………………………………………………………. Contact phone number…………………………….Method of payment…………………(payroll/invoice monthly/DDR/STO/debit/creditcard/on line payments/cheque)------------------------------------------------------------------------------------------------------------------