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Quality Retirement Homes

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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

Applicant 1 (MUST be aged 55 or over)

Applicant 2

(Please tick the relevant boxes below)

 I am interested in living at Upwell Park I am interested in living at Wheel Centre I am interested in living at Elliott Lodge I have no preference


Please provide us with a brief outline of your medical history, including any current medication that you may be taking.

Applicant 1

Applicant 2

Are you currently receiving Attendance Allowance (or Disability Living Allowance/PIP if under the age of 65)?

 Yes No

If YES, who receives this?

 Applicant 1 Applicant 2

Do you anticipate that you will need to claim Housing Benefit to assist with your rent payments?

 Yes No

Do you currently receive Pension Credit

 Yes No
If YES, is this:
 Guaranteed Pension Credit Saving Pension Credit

I / We understand that the completion of this Expression of Interest form does not necessarily mean that
I / We will be placed on a waiting list or offered accommodation.

Signed by applicant 1*


Signed by applicant 2


*Please note that by clicking submit on this form you are acknowledging the terms displayed above & understand that the submission will be considered as acceptance.

If you would like to add any medical information to your application, please do so below:

Applicant 1

Applicant 2

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**