Application Form for Residence

Application for Residence Form

Your Contact Information

Title

Surname

Forenames

Known As

Home Address

Postcode

Email

Home Telephone Number

Mobile Telephone Number

About You

Date of Birth (dd/mm/yyyy)

Place of Birth

How Long at Present Address

Number of Years Resident in Guildford with addresses, if different from current address.

Present or Last Job

National Insurance (NI) Number

Personal Interests

Religious Beliefs (if Any)

Type of Current Accommodation (house, bungalow, flat, caravan lodgings or other)

Please state the name and address of the owner

If you own the Accommodation, please give your estimate of its value (£)

How many rooms due you occupy in the accommodation?

Do you share a kitchen? YESNO
Do you share a bathroom? YESNO
Rent / Mortgage Per Month (£)

Do you receive Housing Benefit (HB) YESNO
Council Tax per year (£)

Income (Yearly or Weekly), Savings and Expenses - please also state if none.

Pay (£)

State Pension (£)

Occupational Pension (£)

Private Pension (£)

Benefits (£)

Please state the total amount of your investments and other savings (£)

Please list below any regular payments (other than housing, food, fuel and light) that you have to make (£)

Two References

Please give details of two people (not relatives) including your current landlord, if you have one.

REFERENCE 1

Name

Address

Postcode

Email

Telephone Number

Relationship

REFERENCE 2

Name

Address

Postcode

Email

Telephone Number

Relationship

Next Of Kin Contacts

Please give details of your Next Of Kin Contacts.

CONTACT 1

Name

Address

Postcode

Email

Telephone Number

Relationship

CONTACT 2 (If available)

Name

Address

Postcode

Email

Telephone Number

Relationship

Supporting Information

Please tell us why you would like to live at Abbot’s Hospital and why you think we should welcome you into our community.

DECLARATION:

I declare that the information that I have given in this application is true and I understand that any failure to disclose information, or any attempt to mislead the Hospital during the application process, including the interview and the medical examination, will invalidate my application and may lead to any appointment as a resident being set aside without notice.

It must be understood that, if I am appointed, I shall occupy as an Alms-house resident under licence in accordance with Charity Law and as a beneficiary of the Charity. I will not be a tenant. Neither the resident(s) nor any relation or guest of his/hers/theirs will be a tenant of the Charity or have any legal interest in his/her/their Alms-house.

Any regular sum I pay will be a maintenance contribution and not rent.

I am willing to live quietly, without disturbing my neighbours.

I agree that if I become unable to care for myself on a permanent basis I shall, if asked to, find and
move to alternative accommodation.

Declaration Signed By - Name:

Date Declaration Signed (dd/mm/yyyy):

Data Protection Statement:

Abbot’s Hospital is responsible for ensuring that applicants are suitably qualified and may therefore have to investigate applicant’s personal circumstances. The personal data supplied on this form, and other information relating to your application or your care management, will be held on file. Some details may have to be checked or exchanged with other organisations, but none will be disclosed for any inappropriate purpose. You will have access to your personal information on request. All applicants need to understand that data will be kept on file and that, when signing this form, you are signing to agree, explicitly, that Abbot’s Hospital can keep your data for the purposes of administration and management. Your data will be removed when you cease to be an ‘applicant’ for one reason or another or when you leave Abbot’s Hospital if you become a resident if your application is successful. Your data will be kept securely, and it will be kept for no longer than is reasonably required.

I have read and accept Abbot's Hospital Data Protection Terms, as stated above.

Human test: Which is bigger, 2 or 8?