1. Basic Information

Male Female

Mr Mrs Miss Ms

43 week contract 52 week contract summer contract

studio 3 bedroom flat 4 bedroom flat

A 43 week contract normally starts beginning of September, we are flexible with starting dates please email for these.

2. Emergency Contact Detail

Mr Mrs Miss Ms

3. Address

Clapham house
100 John Dobson Street
Newcastle upon Tyne
Telephone 0191 2610134


The North Eastern Trustees Ltd firmly believe that all sections of the community should have equal access to housing, irrespective of race, colour, nationality, ethnic and national origin, religious belief, disability or sexual orientation.

To ensure that this policy is effective, we would be grateful if you could complete the following form. This information is confidential and will only be used to check that our policy is working fairly. Your application for housing will not be affected if you do not wish to complete this questionnaire.

White British
White Irish
White Other
Mixed White and Black Caribbean
Mixed White and Black African
Mixed White and Other
Asian or Asian British Indian
Asian or Asian British Pakistani
Asian or Asian British Bangladeshi
Asian or Asian British Other
Black or Black British Caribbean
Black or Black British African
Black or Black British Other
Chinese or Other Ethnic Group Other
Chinese or Other Ethnic Group Chinese
Refused to answer question


We may need to contact other agencies for information about you so that we can process your application. This could include Local Housing Offices, other Local Authorities, Housing Associations, Probation Service, Police, Benefit Agencies, HMRC, Immigration and Social Services. This information could aid your application.

I give the North Eastern YWCA Trustees Ltd consent to contact my present and/or former landlord, any of the above agencies and any other relevant agencies. I authorise them to disclose any information held by them for the purpose of dealing with my application for housing. I understand that any information given to the North Eastern YWCA Trustees Ltd will only be used by them in relation to may application for housing and will not be used for any other purpose or disclosed to any persons without my permission.

I agree to keep the North Eastern YWCA Trustees Ltd informed of any change to my circumstances.
All information will be treated in the strictest confidence and in accordance with the relevant Data Protection legislation. Please check that you have completed this form correctly, an incomplete or unsigned form will be returned to you.

We use your data for the following purposes:-
• To keep you safe by having knowledge of your medical conditions and Doctor contact.
• To have knowledge of your next of kin in case of emergency.
• To maintain our own accounts and records.
• To liaise with appropriate media

Storing your personal data:-

Your data is stored on a password secured, firewall and virus protected computer for as long as is necessary to comply with UK company law and Inland Revenue requirements.

DECLARATION, AUTHORITY TO SEEK INFORMATION & SIGNATURES: I certify that all the information written on this form is true and accurate in every respect. I understand that if a licence is offered to me providing false information the North Eastern YWCA Trustees Limited reserves the right to investigate legal proceedings to recover possession of the property. I confirm that I have no objection to the North Eastern YWCA Trustees Limited taking whatever steps are deemed necessary to verify the information contained in the application, or any other information subsequently given, in accordance with the relevant Data Protection legislation.

Please note: you have the right to check the accuracy of data. The data will be held 6 years on file in line with policy, then destroyed.

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a. I confirm that I have received a copy of the information and house rules that apply to Clapham House.

b. I confirm that I will abide by the house rules of Clapham House.

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