Application Form

Thank you for your interest in becoming a resident in Christie House or John Crosse House. If you fit our criteria you will be placed on our waiting list following the receipt of this form. When a flat becomes available we will contact you and establish if you are still interested. We would appreciate it if you or your family contact us if you no longer wish to remain on the list.

We appreciate that some of the questions are quite personal. Our trust deed only allows us to appoint persons in need. This need may be financial but could also be emotional, geographical or physical. The contents of the application forms will not be disclosed or shared.

The charity fully conforms to the GDP Regulations.

    [heading "Applicant Details"]

    Applicant

    Add New

    [text_content "Are you applying for Christie House or John Crosse House (slightly larger and suitable for couples)?"]

    [heading "Present Address"]

    Address

    Postcode

    Landline

    Mobile

    Email*

    How did you find out about the almshouses?

    How many years have you lived within Bedford Borough Council/Central Bedfordshire?

    Do you own a car?

    [text_content "We do not have any more parking places for residents with cars"]

    [heading "FINANCIAL CIRCUMSTANCES"]

    This section is important. Please take the time to complete it correctly.
    Please enter the amounts received PER WEEK.

    Earnings

    Government Pension

    Other Pension(s)

    Housing Benefit / Universal Credit

    Income Support

    Other Benefits

    INVESTMENTS – This section must be completed.

    [heading "HOME CIRCUMSTANCES"]

    Are you?*

    [heading "PLEASE STATE YOUR REASONS FOR WANTING TO MOVE"]

    [heading "HAVE YOU APPLIED TO OTHER ALMSHOUSES?"]

    [text_content "Please give details of their names and responses?"]

    [heading "DO YOU HAVE A CAT OR DOG WHO WILL MOVE WITH YOU?"]

    [heading "YOUR HEALTH"]

    Name of GP

    Name of Surgery

    Telephone

    Do you suffer from any chronic (long-term) illnesses?

    Please list you current medications

    [heading "FAMILY"]


    Please give the name of the main relative or friend who would be responsible for you. Do you have a Power of Attorney in place with this person named as Attorney (highly recommended)?

    Main contact

    Name

    Mobile

    Email

    Address

    Postcode

    Solicitor who holds power of attorney and/or will

    Name

    Telephone

    Address

    Postcode

    [text_content "Please give the names of two people, not family, who have known you for at least three years and can vouch for your good character."]

    Person 1

    Name

    Telephone

    Mobile

    Email

    Address

    Postcode

    Person 2

    Name

    Telephone

    Mobile

    Email

    Address

    Postcode

    [heading "Family Members"]

    [text_content "Please give the details of other family members if applicable:"]

    Family member

    Add New

    [heading "DECLARATION"]

    [text_content "I/we certify that the details in this form are correct to the best of my knowledge and belief and that this application is submitted in good faith. I/we confirm that I/we am/are able to look after myself/ourselves, with the help of family and social services/carers if necessary. I/we accept that if I/we am/are appointed as a resident:"]

    [text_content "I/we shall be (a) licencee(s) not tenant(s). The weekly sum I/we pay will be maintenance contribution and not rent."]

    [text_content "I/we agree to pay maintenance contributions as determined by the trustees and abide by the rules concerning general conduct of the Almshouses."]

    [text_content "I/we agree to the trustees seeking a medical reference from my/our doctor."]

    [text_content "I/we agree to paying for a landline in the flat. This is currently required for the care alarm (although this may change in the future)"]

    [heading "Sending this form acknowledges agreement to the above terms"]

    General Data Protection Regulations 2018 – it is part of the trustee responsibilities to ensure that applicants for almshouses are suitably qualified under the terms of the charity’s governing instrument. Trustees, therefore, need to investigate the personal circumstances of applicants. The personal data supplied on this form, and other information relating to your almshouse appointment or your care management, will be held securely and never shared with third parties. You may have access to your personal information on request. The charity is compliant with the General Data Protection Regulations 2018