Apply for Housing

Apply Online

	If you are the tenant of another Housing Association or Council and live within the Merseyside area you cannot apply for housing with Pierhead (unless you are applying for sheltered housing), instead you should contact your landlord to discuss your rehousing options. Please tick you confirm you are not the tenant of another HA/Council *

	You must be over 18 to apply for housing. Please confirm that you are over 18. *
	Do you wish to apply for Sheltered Housing? *	Yes No

1. YOUR DETAILS

Title *

First Name *

Surname *

Address *

Line 1
Line 2
Town
County
Postcode
Country

Preferred Contact Number

Other Contact Number

Date of Birth *

National Insurance Number *

Email address

2. YOUR HOUSEHOLD

How many people will be moving with you? *

Please give details (if applicable) about the 1st person who will be moving with you

First Name

Surname

Date of Birth

National Insurance Number

Relationship to Applicant

Gender

Please give details (if applicable) about the 2nd person who will be moving with you

First Name

Surname

Date of Birth

National Insurance Number

Relationship to Applicant

Gender

Please give details (if applicable) about the 3rd person who will be moving with you

First Name

Surname

Date of Birth

National Insurance Number

Relationship to Applicant

Gender

Please give details (if applicable) about the 4th person who will be moving with you

First Name

Surname

Date of Birth

National Insurance Number

Relationship to Applicant

Gender

Please give details (if applicable) about the 5th person who will be moving with you

First Name

Surname

Date of Birth

National Insurance Number

Relationship to Applicant

Gender

Partners Current Address (if different from your own)

Line 1
Line 2
Town
County
Postcode
Country

Are you or any of the people wanting to be rehoused with you, expecting a baby? If so, please provide details:

Name of expectant mother

When is the baby due?

Please upload medical confirmation of the pregnancy. (If you are unable to upload, please post or fax to our Head Office address)

3. NEXT OF KIN

Please enter details of your Next of Kin below

First Name *

Surname *

Address *

Line 1
Line 2
Town
County
Postcode
Country

Telephone Number

Relationship to you? *

4. MEDICAL NEEDS
	If you or a member of your household has any disabilities or medical reasons for needing rehousing please give details
	Please upload any documents of support from your doctor or care worker, to support your application. (If you are unable to upload, please post or fax any letters or supporting documents to our Head Office address)
	Please give details of any special adaption you need to your home, for example, ground floor bathroom or room for a wheelchair.
	Are you registered disabled? *
	If 'Yes', please provide your disability number
	Please tell us if anybody else on your application is disabled
	If 'Other People', please give details

5. YOUR INCOME

Please select the options which apply to you:

Working Full-Tiime (Over 24 Hours A Week)
Working Part-Tiime (24 Hours Or Less A Week)
On A Government Training Scheme
Job Seeker
Registered Unemployed
Retired / Pension
Full-Time Student
Long-Term Sick / Disabled
Income Support
Other

If 'Other', please give details

Net weekly pay or benefit

£ per week

Employer's Name

Employer's Address

Line 1
Line 2
Town
County
Postcode
Country

Please select the options which apply to your partner (if applicable):

If 'Other', please give details

Net weekly pay or benefit

£ per week

Employer's Name

Employer's Address

Line 1
Line 2
Town
County
Postcode
Country

6. YOUR PRESENT HOME

Are you? *

If you are currently a tenant, is your tenancy

Is your property *

How many SINGLE bedrooms are there where you live? *

How many DOUBLE bedrooms are there where you live? *

If you live in a flat or maisonette, which floor is it on?

Describe the condition of the property *

What main type of heating is there in the property? *

If 'Other', please state

If you are a tenant, please give the name and address of your landlord (MUST be completed)

Landlord First Name

Landlord Surname

Landlord Address

Line 1
Line 2
Town
County
Postcode
Country

What is the weekly rent?

£ per week

Do you receive Housing Benefit? *

If 'Yes', how much Housing Benefit do you receive?

£ per week

How long have you been at your present address?

months

7. SHARING
	How many people are currently living with you, but will NOT be rehoused with you? *
	Please give details of the 1st person (if applicable) currently living with you, but will NOT be moving/rehoused with you
	First Name
	Surname
	Date of Birth
	Relationship to you
	Gender
	Please give details of the 2nd person (if applicable) currently living with you, but will NOT be rehoused with you
	First Name
	Surname
	Date of Birth
	Relationship to you
	Gender
	Please give details of the 3rd person (if applicable) currently living with you, but will NOT be rehoused with you
	First Name
	Surname
	Date of Birth
	Relationship to you
	Gender
	Please give details of the 4th person (if applicable) currently living with you, but will NOT be rehoused with you
	First Name
	Surname
	Date of Birth
	Relationship to you
	Gender
	Please give details of the 5th person (if applicable) currently living with you, but will NOT be rehoused with you
	First Name
	Surname
	Date of Birth
	Relationship to you
	Gender
	Please select if you currently 'have', 'do not have', or 'share' the following amenities at your current address
	Bath / Shower *
	Inside Toilet *
	Hot Water Supply *
	Seperate Kitchen *
	Living Room *
	Bedroom *

8. HOME OWNERS
	Do you own your own home? *
	Do you own it outright? *
	If you have a mortgage, how much is still owing?	£
	How much do you estimate the property is worth?	£

9. EVICTION
	Are you threatened with eviction? *
	When would you have to leave?
	Please give details of why you are threatened with eviction
	Please upload any evidence of your pending eviction, if applicable. (If you are unable to upload, please post or fax to our Head Office address)

10. YOUR PREVIOUS CIRCUMSTANCES

Please give details of addresses where you have lived over the past 5 years, or since the age of 16 (whichever is the shorter period), commencing with the most recent

Please give details (if applicable) about your 1st previous address

Address

Line 1
Line 2
Town
County
Postcode
Country

Were you 'The Owner', 'A Tenant' or 'Living In' the property?

Who was the Landlord or Occupier?

When did you occupy from?

When did you occupy to?

Why did you leave the address?

Please give details (if applicable) about your 2nd previous address

Address

Line 1
Line 2
Town
County
Postcode
Country

Were you 'The Owner', 'A Tenant' or 'Living In' the property?

Who was the Landlord or Occupier?

When did you occupy from?

When did you occupy to?

Why did you leave the address?

Please give details (if applicable) about your 3rd previous address

Address

Line 1
Line 2
Town
County
Postcode
Country

Were you 'The Owner', 'A Tenant' or 'Living In' the property?

Who was the Landlord or Occupier?

When did you occupy from?

When did you occupy to?

Why did you leave the address?

Please give details (if applicable) about your 4th previous address

Address

Line 1
Line 2
Town
County
Postcode
Country

Were you 'The Owner', 'A Tenant' or 'Living In' the property?

Who was the Landlord or Occupier?

When did you occupy from?

When did you occupy to?

Why did you leave the address?

Please give details of addresses where your partner (if applicable) has lived over the past 5 years, or since the age of 16 (whichever is the shorter period), commencing with the most recent

Please give details (if applicable) about your partner's 1st previous address

Address

Line 1
Line 2
Town
County
Postcode
Country

Was your partner 'The Owner', 'A Tenant' or 'Living In' the property?

Who was the Landlord or Occupier?

When did your partner occupy from?

When did your partner occupy to?

Why did your partner leave the address?

Please give details (if applicable) about your partner's 2nd previous address

Address

Line 1
Line 2
Town
County
Postcode
Country

Was your partner 'The Owner', 'A Tenant' or 'Living In' the property?

Who was the Landlord or Occupier?

When did your partner occupy from?

When did your partner occupy to?

Why did your partner leave the address?

Please give details (if applicable) about your partner's 3rd previous address

Address

Line 1
Line 2
Town
County
Postcode
Country

Was your partner 'The Owner', 'A Tenant' or 'Living In' the property?

Who was the Landlord or Occupier?

When did your partner occupy from?

When did your partner occupy to?

Why did your partner leave the address?

Please give details (if applicable) about your partner's 4th previous address

Address

Line 1
Line 2
Town
County
Postcode
Country

Was your partner 'The Owner', 'A Tenant' or 'Living In' the property?

Who was the Landlord or Occupier?

When did your partner occupy from?

When did your partner occupy to?

Why did your partner leave the address?

11. PREVIOUS EVICTIONS

Have you ever been evicted? *

If 'Yes', please provide the following details

Address you were evicted from

Line 1
Line 2
Town
County
Postcode
Country

Landlord's First Name

Landlord's Surname

Reason for eviction

Date of eviction

12. CONVICTIONS
	Do you or your partner have any criminal convictions including firearm & drug related offences (other than spent convictions as defined in the Rehabilitation of Offenders Act 1974)? *
	If 'Yes', how many convictions do you have? If you fail to disclose a conviction, this may result in Pierhead applying to the County Court for repossessions of any dwellings of which you have been given a tenancy.
	Please give details of your 1st conviction (if applicable).
	Date of Conviction
	Court of Conviction
	Nature of Offence
	Penalty
	Please give details of your 2nd conviction (if applicable).
	Date of Conviction
	Court of Conviction
	Nature of Offence
	Penalty
	Please give details of your 3rd conviction (if applicable).
	Date of Conviction
	Court of Conviction
	Nature of Offence
	Penalty
	Please give details of your 4th conviction (if applicable).
	Date of Conviction
	Court of Conviction
	Nature of Offence
	Penalty
	Please give details of your 5th conviction (if applicable).
	Date of Conviction
	Court of Conviction
	Nature of Offence
	Penalty

13. YOUR OTHER OPTIONS FOR REHOUSING
	We expect that you will already have applied to the Local Authority for rehousing, please tell us the following details
	Have you applied to the Local Authority or another housing association for rehousing? *
	When did you apply?
	Which housing association did you apply to?
	Please give details of any offers

14. WHERE DO YOU WANT TO LIVE?
	First Choice *
	Second Choice
	Third Choice
	Number of bedrooms required *
	What type(s) of accommodation would you accept ? (tick all that apply) *	Bedsit Bungalow Flat House Maisonette Sheltered
	Do you require a ground floor property? *
	Do you have any pets? *

15. PREVIOUS PIERHEAD TENANCY

Have you had a previous Pierhead Housing tenancy? *

If 'Yes', please tell us the address

Line 1
Line 2
Town
County
Postcode
Country

When did you move into the Pierhead property?

When did you move out of the Pierhead property?

16. WHY DO YOU WISH TO MOVE?
	Which of the following apply to you, or anyone wishing to be housed with you? (Tick all that apply) *	You are leaving tied accomodation You have a medical condition You are homeless Landlord selling property Living apart from family Asked to leave by friend(s) Asked to leave by a relative(s) To be near my current employment You are leaving H.M. Forces You need to live near a relative(s) to give or receive support You need to live near a friend(s) to give or receive support You live in a property which is too large You live in a property which is too small Your relationship has broken down To leave home / gain independance Leaving a hostel Can't afford present housing Building Society repossession Physical Abuse Sexual Abuse Other forms of Abuse Sexual Harassment Racial Harassment Other forms of Harassment Other Reason(s)
	For each box you have ticked above, please give details, including any other information you would like to give us to help your application *
	Please post, fax or hand in any letters to our Head Office, which support your application i.e. letters from the Police, support workers or proof of access to children. Or if you have an electronic copy, please upload

18. RELATIONSHIP TO PIERHEAD HOUSING STAFF / COMMITTEE MEMBERS
	If you are an employee, or a member of the Association or related to one, please give details.

19. EQUAL OPPORTUNITIES
	We are committed to fighting discrimination and inequality in the service we provide to the public. To help us monitor the success of our equal opportunities policy. It would be helpful if you could fill in this form. if you do not want to fill in this form it will not prejudice your application. We will not pass on the information you give us to anyone else, and will only use it to monitor, develop and improve our housing policy.
	Please tell us which racial group you belong to *
	Racial Group Person 2
	Racial Group Person 3
	Racial Group Person 4
	Racial Group Person 5
	Racial Group Person 6
	If you think that the categories above do not include your racial group, you can use this space to tell us your racial group

20. AGREEMENT
	If rehoused by Pierhead Housing do you agree to your name and address being released to the Local Authority, for their information? *

21. REFERENCES
	Anyone applying to Pierhead Housing must provide references to show they will conduct a tenancy in a satisfactory manner. You will need to send in 2 references, one of which must be from your current or previous landlord. The other reference must be on letter-headed paper from someone who knows you in an official capacity; this must not be a friend, relative or neighbour. Examples of people who we will accept the reference from are your employer, local commuity representative, advice worker, health visitor, social worker, probation officer. Please foward these documents within 2 weeks of submitting your application form.
	We will also require 2 proofs of residence for all adults listed, for example, current bank statements, recent paid utility bill, driving licence, or letter from benefit agencies for all adults. For all children listed 1 proof of residence is required, for example, Child Benefit Book or Child Beneift Agency letter showing all the children. We will also require proof of National Insurance Number for you (the main applicant). Please send this evidence in, along with your references, within 2 weeks of submitting your application form.

DECLARATION AND UNDERTAKING
	I/We declare that the information given in this form is complete and correct and agree that Pierhead Housing may make any enquiries it feels necessary. *
	By submitting this form you accept that Pierhead Housing will also process your application for participation in the Liverpool Property Pool, a choice based lettings scheme for Registered Landlords properties in Liverpool. The following landlords participate in the scheme: Pierhead, Arena, Berrybridge, CDS, Cobalt, Community Seven, Cosmopolitan, Hornby Homes, Lee Valley, LHT, Liverpool Mutual Homes, Maritime, Riverside, Servite Houses, South Liverpool Housing and Venture Housing. Property Pool requires internet access and properties are advertised every Tuesday through to midnight on a Sunday. For more information visit the website www.propertypool.org.uk *
	DATA PROTECTION 1998 By submitting this form, you understand that in order to process your application we must share information which you have provided with all the agencies mentioned. All information which you have provided is processed in accordance with the Data Protection Act 1998 and the obligations which are placed on Data Controllers. The information provided may also be shared with other landlords, or we may contact previous landlords to ask for references. Some information which you have provided may also be used to check the accuracy of your application and for the prevention and detection of a crime, with the following agencies: the Department of Work and Pensions, Police, Probation Services, Liverpool City Council, Sefton MBC, Wirral MBC and Knowsley MBC as well as internal departments within Pierhead Housing. The information which you have supplied will be used to validate your application based on the household make up and letting criteria and also for the purpose of ensuring/detecting fraudulent claims are not being processed. *
	DECLARATION As far as I know the answers given on this form are true. I understand that if I, or anyone acting on my behalf, have given false information or withhold relevant information you can reject my application and that I may loose any tenancy granted. I understand that all the information I have given will be put on the landlord’s (Pierhead’s) computer system and that I need to tell you immediately if there is any change in my circumstances. I understand that by signing this declaration I am giving permission to contact any previous landlords and relevant agencies mentioned to check the information I have given and for them to release any relevant information. I agree to the information provided being shared with other housing agencies and used for research and analysis. *