Disabled Persons’ Accommodation Agency
On-line Registration Form
Applicant’s details The applicant does not necessarily need to be the person with a physical disability or sensory impairment - it should be the person to be contacted on any matters concerning the information given on this form or if a possible property becomes available.
Last name
Title
First names
Date of birth
(dd/mm/19yy)
Present address:
Postcode:
Telephone (inc code):
Minicom:
If you are seeking accommodation within the public sector please complete the following table:
Members of Household Please detail everyone who will be living with you, including a carer if you are expecting to have one.
Age
Relationship to you - e.g., son, mother, carer...
Current Housing
Please select the option most that most appropriately describes your circumstances
--- Please Select --- Owner Occupier Council Tenant Housing Association Tenant Tenant with Private Landlord Living with Parents Other
Physical Impairment
Please click the appropriate box(es)
(hold down Ctrl + left click to select more than one option)
Most wheelchairs are 640 millimetres wide (just over 25 inches ) If you have a wide wheelchair (particularly relevant if you require it for indoor use), please give its width: Inches Centimetres Millimetres
Sensory impairment
If you have a sensory impairment please select from those listed : --- Please Select --- Not Applicable Impaired Hearing Impaired Eyesight Both Hearing and Eyesight impaired
Location
Where would you like to live? Please click the district council areas that you would like to live in. Tick as many as necessary (hold down Ctrl + left click to select more than one area)
Gravesham Dartford Medway Swale Canterbury Thanet Dover Shepway Ashford Tunbridge Wells Tonbridge & Malling Sevenoaks Maidstone ANY AREA
Other (Please specify)
If you wish, name the towns, areas or districts within these areas that you would like to live in. You can be as general or specific as you want to be, but bear in mind that the smaller the area, the more difficult it will be for us to find appropriate accommodation for you:
About your housing requirements:
Select one or more of the following: (hold down Ctrl + left click to select more than one option)
Are you looking for: (hold down Ctrl + left click to select more than one option)
If you selected 'Other' please specify
If you wish to purchase a property what price are you prepared to pay? --- Please Select --- Not Applicable up to £40,000 £40,000 - £50,000 £50,000 - £60,000 £60,000 - £70,000 £70,000 - £80,000 £80,000 - £90,000 £90,000 - £100,000 £100,000 - £125,000 £125,000 - £130,000 £130,000 - £140,000 £140,000 - £150,000 £150,000 - £160,000 £160,000 - £170,000 £170,000 - £185,000 £185,000 - £200,000 £200,000 +
Do you require: (hold down Ctrl + left click to select more than one option)
If you wish to rent a property please complete the following questions:
These questions are not obligatory for those wishing to purchase a property However, please complete the questions if you wish as they provide us with valuable statistics
Do you have:
If you have pets, please give number and type:
Any other information Please give any other information which you would like us to take into account when considering your housing requirements:
What rent are you prepared to pay on a monthly basis?
Do you receive or will you expect all or part of your rent to be met by Housing Benefit? Yes / No Yes No
If you will be receiving/already receive Housing Benefit, what is the current/potential rate per month?
For our records The information in this section is only used to help us to monitor the fairness and effectiveness of our service.
Where did you find out about the DPAA ? --- Please Select --- Advice centre/line Disability group Doctor/nurse Housing Association Hospital Leaflet Landlord Newsletter Occupational Therapist Press Social Services Internet DPAA Staff Word of Mouth Radio/TV Local Council Another source
What is your ethnic origin? --- Please Select --- Afro-Caribbean African Asian European (white) European (black) Other... please specify Decline invitation to take part
The information supplied on the application form will be held on a computer, in compliance with the Data Protection Act 1998.