Application Form

Personal details

First name(s)*:
Surname*:
Gender / Preferred pronouns*:

Your gender could be male, female, or whatever other gender you identify as. Your pronouns are how you would like us to refer to you, such as he/him, she/her, they/them, etc.

Date of birth*:
Ethnicity*:
Religion*:
House number/street name:
Town/city:
County:
Postcode:
Email address*:
Contact phone number*:

About you and your household's needs

Preferred language*:
Other languages spoken*:
Do you smoke?YesNo
Do you own any pets?*
Do you have any dependents who will be living with you? If so what are their names and ages?
What size flat are you applying for?1 bedroom2 bedrooms3 bedrooms
If you are planning to share the flat with another adult please enter their name so we can consider your membership together
Do you have any access requirements (e.g. ground floor access needed, hearing aids in meetings, BSL interpretation)

About your financial situation

Do you work? If so what is your rough income level?NoLess than £10,000£10,000 - £20,000£20,000 - £30,000£30,000 - £40,000More than £40,000
Are you currently claiming housing benefits / universal credit / PIP? If so, which?

Eligibility

Do you own a property?YesNo
Do you understand that there will be no Right to Buy on any properties in the Stirchley Cooperative Development?YesNo
Describe your connection to the local area
Are you planning to bring any vehicles with you?

Co-op living

Why do you want to live in a co-op?
Have you ever been involved in a co-operative organisation before?
Do you feel that you would have the time and capacity to contribute to the work involved in living in SCD?
Which working group(s) do you think you might be interested in joining?*

Possible working groups: Membership, Upstairs (housing), Downstairs (worker co-ops), Outdoor spaces, Finance, Tech & I.T., Secretarial, Publicity & Outreach, Support & Inclusion, Democracy

Further questions

Is there anything else you would like to tell us about yourself or your household?
Do you have any reservations or concerns about being a member of SCD?
Do you have any further questions about SCD?

Housing need

If you are a social housing tenant (i.e. applying for social housing) please tell us which priority band (A, B, C, D) you have been awarded and why.

If you are not a social housing tenant please tick any of the following list which apply to you:

We will use this information to create a housing needs score, we may seek clarification and alter your score at the interview stage.

I currently have no fixed abodeI am currently in temporary accommodationI currently have no secure tenancyI am currently living with family/friends (without own tenancy)I am currently housed at a Bed and BreakfastI have a current notice to quit my propertyI have impending homelessness within next 28 days

I have recently split up with my partner but I am unable to leave our shared accomodationI am currently experiencing domestic abuse (this includes physical, emotional, financial abuse from a current or ex partner or family member you currently live with)I am currently experiencing mental cruelty within my family (whom I am living with)I am currently experiencing harassment by partner, former partner or family member whom I do NOT live withThere is currently a serious risk of violence to my child (under 18)I am currently experiencing violence from a neighbour/friend/community memberI am currently experiencing harassment, including property damage, from a neighbour/friend/community memberI am currently experiencing verbal harassment from a neighbour/friend/community member

I am currently experiencing overcrowding in my property (separate room needed for couple/single parent)I am currently experiencing overcrowding in my property (separate room needed for individual under 18)I am currently experiencing overcrowding in my property (children of opposite sex sharing room)I am currently experiencing overcrowding in my property (children of same sex with 4 yr age gap sharing room)I am currently experiencing overcrowding in my property (more than two children sharing room)I am currently experiencing overcrowding in my property (person 16 years or older sharing room)

I am lacking facilities in my current property including (tick all that apply):

No inside toiletNo hot waterNo cooking facilitiesNo space heating (if you are OAP, kids under 13, disabled)Kitchen shared (with separate household)Bathroom shared (with separate household)

I currently have a notice from Environmental Health confirming my property is unfit/unsafe to inhabitThere is a general lack of repair in my current property likely to endanger my healthMy current property is in a poor state of repair and condition

I am part of a family with children currently living in high rise flats (above 3rd floor)I am part of a family with children and my property lacks security/safety for themI am part of a family with children with no garden or safe play area nearbyI am currently pregnant or registered for fostering/adoption and my current accomodation is unsuitable

I am physically unable to maintain my current propertyI am experiencing anti social behaviour from neighbours in my current propertyMy current household environment is adversely affected (e.g. exacerbates health condition) by another person I live with (who is not a partner or family member)I am financially unable to maintain my current propertyI am currently housed a great distance from family/support networkI am currently housed a great distance from my current employment (and need to physically be there)I am currently housed a great distance from training/community/place of worship

I am a care leaver under the age of 25I am or was previously a member of Her Majesty's Armed ForcesThe Council has approved demolition/clearance on my current propertyI am currently in need of or need to provide greater social support for my/my children's needs

I am currently in receipt of disability benefits such as PIP, DLA, ESA or other disablity related benefitsI have a chronic health condition or illness made worse by my current living conditionsI have a chronic health condition or illness with mobility issues made worse by my current living conditions

I have children but we currently unable to live together due to current housing conditionsI am unable to live with my family (and wish to) currently due to current housing conditions (no children)

None of the above