Coventry

Wednesday, 19-Nov-2008

Online application form

About you

Data Protection

The information you provide on this form will be used and stored in accordance with the Data Protection Act 1998 to provide and manage housing. We will use this information to process your application for housing, develop our business and provide statistical information. We may share your information and make any other necessary enquiries regarding your Application with other housing providers and Statutory organisations to help us manage properties, handle claims and prevent fraud. Under the terms of the act you have the right to see the information we hold about you.

If you have previously started an online application, then enter your reference number and date of birth below to log in.

Reference number:

Date of birth: (dd/mm/yyyy)

Otherwise, please start entering your information below. Note that questions marked with * are mandatory for you to answer.

About you

Title:*

Surname:*

First name:*

Previous surname/names if any:

Address line 1:*

Address line 2:*

Address line 3:

Address line 4:

Postcode:*

Date moved in to this address:* (dd/mm/yyyy)

Home telephone:

Work telephone:

Mobile telephone:

E-mail address:

National insurance number:

Date of birth:* (dd/mm/yyyy)

Gender:*

Ethnic origin:*

Nationality:*

Note: EEA refers to the European Economic Area and it includes all European Union countries as well as Iceland, Norway, Liechtenstein.

If other nationality please specify

Immigration status*

Sexuality

Religion

Pregnant? yes no

If yes, then when is the baby due: (dd/mm/yyyy)

Child access: yes no

Child access details:

Correspondence address

Same address as main applicant: yes no

If yes, then please ignore the following address fields

Address line 1:*

Address line 2:*

Address line 3:

Address line 4:

Postcode:*