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1245 Rang Raod, medical, E152 95RB

Telephone: (922) 3354 2252

demo@example.com

Time: 9.00am-4.00pm

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Full Name

Date of Birth

Mobile Phone

Email Address

Current Address

Household Details-Adults

Household Details-Children

Household Details- Children's Ages

Current Housing Situation

Accommodation Requirements

Accommodation Requirements-Accommodation Needed From

Accommodation Requirements-Special Requirements

Ground Floor Wheelchair Access Family Room Near Public Transport

Income & Support-Main Income Source

Income & Support-MSD Client Number

Income & Support-Support Agency / Case Manager

Health & Accessibility

Safety & Accommodation Assessment-Have you ever been convicted of a criminal offence?

Yes No

Are you currently subject to Bail Conditions, Parole Conditions, Community Corrections requirements or Court Orders?

Yes No

Have you ever been asked to leave a motel, hotel, emergency housing provider, boarding house or rental property?

Yes No

Do you smoke or vape?

Will anyone in your household smoke or vape?

Yes No

Do you have any pets?

Yes No

Have you previously stayed in emergency accommodation?

Yes No

Referral Information-How did you hear about us?

Were you referred by an organisation?

Yes No

Emergency Contact

Additional Information

Declaration

I declare that the information provided is true and correct. I understand that submitting this application does not guarantee accommodation.

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Housing First
Rapid Rehousing
Transitional Housing

Founded on the Christian principles of Justice, Mercy, and Compassion with a deep respect for Te Tiriti o Waitangi, the Trust has continually evolved – responding to community voices, embracing Kaupapa Māori, and pioneering innovative services that create opportunities for lives to be transformed.

Phone:021331500
Email:info@aehs.co.nz