Application for Rental Housing Survey

Privacy
The personal Information collected on this form will only be used by the Shire of Dumbleyung for the sole purpose of providing requested and related services. Information will be stored securely by the Shire and will not be disclosed to any third parties without your express written consent.

Copyright
I authorise the Shire of Dumbleyung to reproduce any attachments provided with this form for internal purposes only.

Warning
It is important the details or your application are true and accurate. A false declaration will result in the withdrawal of your application and the loss of your place on the waiting list.

Question Title

* PROPERTY ADDRESS APPLICANT IS APPLYING FOR

Question Title

* APPLICANT #1 DETAILS

Name

Date of Birth

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* Previous Rental History

Address of Rental Property

Rent Paid per week

Rent Paid to (property manager/lessor name)

Property Manager/Lessor Address

Property Manager/Lessor Phone Number

Dates Rented (move in and move out dates)

Reason for leaving

Question Title

* Do you own or are you in the process of buying residential land or property?

Yes

If yes please state why you are renting?

Question Title

* Have you had previous housing assistance under another name?

Yes

Give details below

Question Title

* Have you had rental applications previously denied?

Yes

If Yes, please provide details.

Question Title

* Employment/Financial Details (if self employed less than one year, give previous employer)

Occupation

Employer

Employer's Address

Employment dates (dates started and left)

Contact Name

Contact Phone

Net Income per Week

Net weekly income from other sources

Centrelink Details (If Applicable please state Pension Type and amount)

Question Title

* NATIONALITY
Are you of Aboriginal or Torres Strait Islander Origin

Yes

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* Do you speak English?

Yes

If no, what language is spoken?

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* Were you born in Australia

Yes

If No, what country were you born in?

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* Are you an Australian Citizen or permanent Resident?

Yes

DISABILITY/MEDICAL INFORMATION

It is in your best interest to advise the Shire of Dumbleyung Council if anyone in your household has a disability or medical conditions so that the most suitable allocation of housing can be made.

Question Title

* Does any member of your household have a disability which impacts on their household needs? (If YES please complete the Disability Form)

Yes

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* Does any member of your household have a medical condition that you wish to be considered as part of your application? (If YES please complete the Medical Information form.)

Yes

Question Title

* Personal References (Two required)

Name

Relationship to Applicant

Contact phone

Address

Name

Relationship to Applicant

Contact Phone

Address

Question Title

* Next of Kin

Name

Relationship

Home Phone

Mobile Phone

Work Phone

Address

Question Title

* Emergency Contact

Name

Relationship

Home Phone

Mobile Phone

Work Phone

Address

Question Title

* APPLICANT #2 DETAILS

Name

Date of Birth

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* Previous Rental History

Address of Rental Property

Rent Paid per week

Rent Paid to (property manager/lessor name)

Property Manager/Lessor Address

Property Manager/Lessor Phone Number

Dates Rented (move in and move out dates)

Reason for leaving

Question Title

* Do you own or are you in the process of buying residential land or property?

Yes

If yes please state why you are renting?

Question Title

* Have you had previous housing assistance under another name?

Yes

Give details below

Question Title

* Have you had rental applications previously denied?

Yes

If Yes, please provide details.

Question Title

* Employment/Financial Details (if self employed less than one year, give previous employer)

Occupation

Employer

Employer's Address

Employment dates (dates started and left)

Contact Name

Contact Phone

Net Income per Week

Net weekly income from other sources

Centrelink Details (If Applicable please state Pension Type and amount)

Question Title

* NATIONALITY
Are you of Aboriginal or Torres Strait Islander Origin

Yes

Question Title

* Do you speak English?

Yes

If no, what language is spoken?

Question Title

* Were you born in Australia

Yes

If No, what country were you born in?

Question Title

* Are you an Australian Citizen or permanent Resident?

Yes

Question Title

* PETS
Do either applicants have any Pets (a pet bond will apply for dogs & cats and may apply for other animals if applicable)

Yes

If Yes, please specify what pets.

Question Title

* Does any member of your household have a disability which impacts on their household needs? (If YES please complete the Disability Form)

Yes

Question Title

* Does any member of your household have a medical condition that you wish to be considered as part of your application? (If YES please complete the Medical Information form.)

Yes

Question Title

* Personal References (Two required)

Name

Relationship to Applicant

Contact phone

Address

Name

Relationship to Applicant

Contact Phone

Address

Question Title

* Next of Kin

Name

Relationship

Home Phone

Mobile Phone

Work Phone

Address

Question Title

* Emergency Contact

Name

Relationship

Home Phone

Mobile Phone

Work Phone

Address

Question Title

* DISABILITY INFORMATION FORM (IF APPLICABLE)

Name of Person with Disability

Date of Birth

Do you require assistance with verbal communication (eg advocate/interpretor)?

Advocate/Interpretor Name (If Applicable)

Advocate/Interpretor Work Phone

Advocate/Interpretor Mobile Phone

Advocate/Interpretor Email Address

Question Title

* DETAILS OF DISABILITY
Physical (eg. Paraplegic, Stroke, Cerebral Palsy, Arthritis)

Yes

Give Details Below

Question Title

* Sensory (eg. blind, Deaf)

Yes

Give Details Below

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* Intellectual

Yes

Give Details Below

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* Psychiatric

Yes

Give Details Below

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* Other

Yes

Give Details Below

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* Support Needs
Do you require support to assist you to live independently?

Yes

What date was support applied for?

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* What level of support do you need to live independently and who will provide this support? (eg 24 hour support, 2-3 hours a day and family, Disability Services Commission, HACC ACTIV, Silverchain etc)

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* Has the Support been approved? (If Yes please supply a copy of the support letter)

Yes

Estimated date when support will be available

Question Title

* Copy of the support letter (If Applicable)

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

Question Title

* HOUSING NEEDS
Are Modifications required to:

Bathroom

Kitchen

Toilet

Other (please specify)

Question Title

* Is the person with the disability a permanent wheelchair user?

Yes

If YES what type of wheelchair? (Electrical/Manual)

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* Is accommodation without steps required?

Yes

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* Do you need to be near:

Medical Facilities

Community Facility/Shops

Other (please specify)

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* If you have ticked any of the above, please state why (if any modifications are required, a report from an Occupational Therapist is required and can be uploaded at the next section):

Question Title

* Report from Occupational Therapist (if applicable)

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

MEDICAL INFORMATION
There is a form for applicants who wish to have their medical condition considered as part of the application for appropriate housing however it is a form for a Doctor to complete and therefore would need to be obtained from the Shire of Dumbleyung directly. Please phone 0898634012 or email ybairstow@dumbleyung.wa.gov.au for this form.

Application for Rental Housing

Question Title

* PROPERTY ADDRESS APPLICANT IS APPLYING FOR

Question Title

* APPLICANT #1 DETAILS

Question Title

* Previous Rental History

Question Title

* Do you own or are you in the process of buying residential land or property?

Question Title

* Have you had previous housing assistance under another name?

Question Title

* Have you had rental applications previously denied?

Question Title

* Employment/Financial Details (if self employed less than one year, give previous employer)

Question Title

* NATIONALITYAre you of Aboriginal or Torres Strait Islander Origin

Question Title

* Do you speak English?

Question Title

* Were you born in Australia

Question Title

* Are you an Australian Citizen or permanent Resident?

Question Title

* Does any member of your household have a disability which impacts on their household needs? (If YES please complete the Disability Form)

Question Title

* Does any member of your household have a medical condition that you wish to be considered as part of your application? (If YES please complete the Medical Information form.)

Question Title

* Personal References (Two required)

Question Title

* Next of Kin

Question Title

* Emergency Contact

Question Title

* APPLICANT #2 DETAILS

Question Title

* Previous Rental History

Question Title

* Do you own or are you in the process of buying residential land or property?

Question Title

* Have you had previous housing assistance under another name?

Question Title

* Have you had rental applications previously denied?

Question Title

* Employment/Financial Details (if self employed less than one year, give previous employer)

Question Title

* NATIONALITYAre you of Aboriginal or Torres Strait Islander Origin

Question Title

* Do you speak English?

Question Title

* Were you born in Australia

Question Title

* Are you an Australian Citizen or permanent Resident?

Question Title

* PETSDo either applicants have any Pets (a pet bond will apply for dogs & cats and may apply for other animals if applicable)

Question Title

* Does any member of your household have a disability which impacts on their household needs? (If YES please complete the Disability Form)

Question Title

* Does any member of your household have a medical condition that you wish to be considered as part of your application? (If YES please complete the Medical Information form.)

Question Title

* Personal References (Two required)

Question Title

* Next of Kin

Question Title

* Emergency Contact

Question Title

* DISABILITY INFORMATION FORM (IF APPLICABLE)

Question Title

* DETAILS OF DISABILITYPhysical (eg. Paraplegic, Stroke, Cerebral Palsy, Arthritis)

Question Title

* Sensory (eg. blind, Deaf)

Question Title

* Intellectual

Question Title

* Psychiatric

Question Title

* Other

Question Title

* Support NeedsDo you require support to assist you to live independently?

Question Title

* NATIONALITY
Are you of Aboriginal or Torres Strait Islander Origin

* NATIONALITY
Are you of Aboriginal or Torres Strait Islander Origin

* PETS
Do either applicants have any Pets (a pet bond will apply for dogs & cats and may apply for other animals if applicable)

* DETAILS OF DISABILITY
Physical (eg. Paraplegic, Stroke, Cerebral Palsy, Arthritis)

* Support Needs
Do you require support to assist you to live independently?

* HOUSING NEEDS
Are Modifications required to: