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Personal details
Your home
Finances
Health & Social
References

    • 1

      About You

    • 2

      About Your Family

    • 3

      About Your Home

    • 4

      About Your Home

    • 5

      Your Income

    • 6

      Your Income

    • 7

      Your Income

    • 8

      Health and Social

    • 9

      References

    • 10

      Declaration

    1/10

    About You

    Personal details


    Address and contact details

    Employment history

    Please give details of any occupations you have followed and for how long. Any present occupations should be included:

    GP details

    Address and contact details

    Employment history

    Please give details of any occupations you have followed and for how long. Any present occupations should be included:

    GP details

    Next of kin details in case of emergency

    Your current living situation

    Please complete this section if you live in rented accomodation

    Please give the name and address of your Landlord

    Your current living situation continued

    To enable the trustees to assess your application, please provide the following information:

    Please complete all sources of income and how regularly you receive them. Leave fields blank if they are not relevant to you:

    To enable the trustees to assess your application,
    please provide the following information:

    Please complete all sources of income and how regularly you receive them.
    Leave fields blank if they are not relevant to you:


    To enable the trustees to assess your application,
    please provide the following information:

    Please complete all sources of income and how regularly you receive them.
    Leave fields blank if they are not relevant to you:

    ?

    About your health and social factors:




    ?

    Reference details

    Please give the names and addresses of two responsible people (not relatives) who know you well and whom the charity may approach for a character reference.

    Referee 1












    Referee 2












    Please read and sign before submitting the form:

    I have read the charity’s Conditions of Entry and believe that I am eligible to apply to live in
    one of the charity’s almshouses. I declare that the information given in this application is correct
    and complete to the best of my knowledge and belief.

    I accept that if I am appointed as a resident I shall be a Licensee of the charity and not a tenant.
    Any weekly sum I pay will be a maintenance contribution and not a rent. If elected agree to abide
    by the rules governing the Almshouses. I confirm that I am able to look after myself, with the assistance of family and social services if necessary.

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