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Rosebery Housing Association,
Rutland House,
57-59 South Street,
Epsom, Surrey KT18 7PR.

01372 814 000
0800 068 7664 free phone

Click here for directions to Rosebery
Transfer Application Form

Section 1 about you and your family
Your title:  Mr    Mrs    Ms    Miss
Your Name

Partners Name

Your address
 Day time phone number


Evening phone number


Mobile number

Email Address
Give details of the people who would live with you if you were offered a transfer.
Put your own details first.
First name:

Date of birth:
 Sex: Male
Female

Relationship to you:

 Surname:

Your address

First name:

Date of birth:
 Sex: Male
Female

Relationship to you:

 Surname:

Your address

First name:

Date of birth:
 Sex: Male
Female

Relationship to you:

 Surname:

Your address

First name:

Date of birth:
 Sex: Male
Female

Relationship to you:

 Surname:

Your address

First name:

Date of birth:
 Sex: Male
Female

Relationship to you:

 Surname:

Your address

Is anyone in the family pregnant?:  Yes    No  
If YES, please state name and when the baby is due
(you will need to provide evidence i.e. maternity certificate)
Is anyone in the family registered disabled?:  Yes    No  
Please provide the name, address and contact details of the next of kin
Name:
Address
 Day time phone number


Evening phone number


Mobile number

Your national insurance number
Your partner's national insurance number

Section 2 about your current accommodation

Do you live in a:
 Caravan
 Bed and Breakfast
 Mobile home
 Maisonette
 Flat
 Room
 Bungalow
 House
Other - please describe
What floor is your property on? (eg ground, first, second etc)
Identify the following facilities you and other members of your family applying for housing currently have
Number Shared Sole use
Living room
Bedrooms
Bathroom/shower
Toilet (internal)
Toilet (external)
Kitchen
Do you have any pets?

  Yes   No

If yes, please give details

Is there a Court Order/Notice of Seeking Possession on your home?

  Yes   No
Is your property in a poor state of repair?

  Yes   No

If yes, please give details below and include a report from the Environmental Health Department if relevant

Section 3 For elderly applicants only

If you have a garden, do you have difficulty maintaining it?

  Yes   No

Do you wish to be considered for:
 Older persons dwelling - warden assisted
 Older persons dwelling - without warden
 General purpose dwelling

Section 4 Medical problems

Do you, or any person to be housed with you, have any medical problems that are made worse by your current housing. If yes, please complete the following table as fully as possible.

  Yes   No
First name:

Illnes or disability:

Medicines prescribed at present:

 Surname:

Full name and adress of doctor/hospital/clinic/consultant
atteneded in last 12 months


Explain how your present accommodation makes worse the medical circumstances of the persons listed. Indicate if any persons experience difficulty with steps/stairs/walking and have use of walking aids (ie wheelchair or walking frame). If registered disabled please provide number on registration card.
Does anybody in your household require wheelchair adapted accommodation?

  Yes   No

Section 5 Please tell us your main reasons for requesting housing

Also, list anything else not covered in this form you think may be relevant
Are you or your partner related to any employee or board member of Rosebery Housing Group

  Yes   No
Name:

 Position (i.e.board member, housing officer)

Rosebery Housing Association keeps social and ethnic records in order to assess the extent to which racial discrimination might prevent households gaining equal access to our accommodation. However, if you do not wisdh to complete this section, it will not affect your application for housing
How would you describe your ethnic origin? Do you consider yourself to be:

 White You Your partner
 British
 Irish
 Other
 Mixed You Your partner
 White/black Caribbean
 White/black African
 White Asian
 Other
 Asian/Asian British You Your partner
 Indian
 Pakistani
 Bangladeshi
 Other
 Black/black British You Your partner
 Caribbean
 African
 Other
 Chinese/other ethnic group You Your partner
 Chinese
 Other
If your first language is not English, please specify

Section 6 Please give three choices of where you would like to live within our housing stock

Some areas have very few properties available so your wait will be longer if you choose such an area. Further information is available on request:
Shared ownership
If you are interested in shared ownership, please contact the Housing Department at Epsom and Ewell Borough Council for further information
Mutual exchange
Are you interested in moving within this area by mutually exchanging your property?

  Yes   No
Are you interested in moving to another area?

  Yes   No
If yes, please specify
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Rosebery Housing Association telephone: 01372 814000
   mailto:customerservices@rosebery.org.uk