Customer 1 title:
Mr Ms Miss Mrs

Customer 1 name:

Customer 1 date of birth:

Customer 1 National Insurance number (if known):

Customer 2 title:
Mr Ms Miss Mrs

Customer 2 name:

Customer 2 date of birth:

Customer 2 National Insurance number (if known):

Address (required):

Postcode:

Telephone number (required):

Email address:

Please give details of name, date of birth and relationship of any other occupants (for example child, parent etc):

Any special communication needs (for example, tape)?

Do you own your property?
Yes
No

If rented, who is the landlord?

Are you claiming any benefits?
Yes
No

If yes, please state which:

Do you have any medical conditions?
Yes
No

If yes, please give details:

What type of property and area are you looking for?

Are you registered on any housing lists already? If so, please give details:

How did you hear about the service:

Has a risk assessment been carried out?
Yes
No
Don't know

If yes, please give details of any risk identified

Ethnic origin (please select how you would describe your ethnicity):

White:
Welsh
Irish
English
Scottish
Other

Black:
Black
British
African
Caribbean
Other

Asian:
British
Indian
Pakistani
Other

Chinese:
British

Dual heritage (please specify):

Other (please specify):

If you filling in this form on behalf of a client could you give us the following details:

Your name:

Your phone number:

Relationship to the client: