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.

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* PROPERTY ADDRESS APPLICANT IS APPLYING FOR

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* APPLICANT #1 DETAILS

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* Previous Rental History

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

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* Have you had previous housing assistance under another name?

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* Have you had rental applications previously denied?

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

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* NATIONALITY
Are you of Aboriginal or Torres Strait Islander Origin

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* Do you speak English?

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* Were you born in Australia

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* Are you an Australian Citizen or permanent Resident?

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.

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

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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.)

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* Personal References (Two required)

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* Next of Kin

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* Emergency Contact

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* APPLICANT #2 DETAILS

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* Previous Rental History

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

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* Have you had previous housing assistance under another name?

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* Have you had rental applications previously denied?

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

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* NATIONALITY
Are you of Aboriginal or Torres Strait Islander Origin

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* Do you speak English?

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* Were you born in Australia

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* Are you an Australian Citizen or permanent Resident?

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

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.

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

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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.)

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* Personal References (Two required)

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* Next of Kin

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* Emergency Contact

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* DISABILITY INFORMATION FORM (IF APPLICABLE)

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

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* Sensory (eg. blind, Deaf)

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* Intellectual

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* Psychiatric

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* Other

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

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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)

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* Copy of the support letter (If Applicable)

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
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* HOUSING NEEDS
Are Modifications required to:

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

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* Is accommodation without steps required?

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* Do you need to be near:

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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):

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* Report from Occupational Therapist (if applicable)

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