Please contact us if you need help reading this form, or if you would like any part of it translating.
Please note that regretfully we do not allow pets
Date of Birth:
Contact Telephone No:
Please provide us with a brief outline of your medical history, including any current medication that you may be taking.
Are you currently receiving Attendance Allowance (or Disability Living Allowance/PIP if under the age of 65)?
Do you anticipate that you will need to claim Housing Benefit to assist with your rent payments?
Do you currently receive Pension Credit
I / We understand that the completion of this Expression of Interest form does not necessarily mean thatI / We will be placed on a waiting list or offered accommodation.
If you would like to add any medical information to your application, please do so below:
Thank you for your time.We will contact you when a suitable vacancy arises. We regret that we are unable to estimate how long you are likely to be waiting.
**The information you have supplied will be treated in the utmost confidence and will not be stored on any computer system**