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Tenancy Application

First Name

Email

Last Name

Day Phone

Evening Phone

Current Address

Are you receving support from a service provider?

Yes

No

If yes, please give details

What is the name of your health serivce provider?

What is the name of your key/support worker?

Their contact number

Are you a New Zealand resident?

Yes

No

Your source of income: if beneficiary, what type of benefit?

I agree to have my rent paid directly from my WINZ benefit

Yes

No

If employed- name of employer, address and contact number

Annual income

Your accomodation requirements- Number of adults

Number of children

Suburb preference (if any)

Are you willing to share a 2-bedroom unit?

Yes

No

Do you smoke?

Yes

No

Referees:

Please provide at least 2 referees/references from the following: your whanau, mental health/social services team or a current or previous landlord

Referee 1 - a member of your whanau

Their relationship to you:

Their contact number

Referee 2 - Mental health/social services team

Their contact number

Referee 3 - Current of previous landlord

Their contact number:

When your application has been approved we may contact you for an interview. Tell us about why you require accomodation:

Any other information you may want us to consider?

This information may be used solely to obtain personal references or to obtain further information to clarify statements made above.

I Agree

Your Name

Date

THANK YOU FOR YOUR APPLICATION!!!

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2/40 Copsey Business Park, Copsey Place, Avondale, Auckland 1026

PO Box 71-129 Rosebank

Auckland 1026

Phone: (09) 820 0045

Fax: (09) 820 5659

Toll Free: (0800) 731 188

Email:

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Tenancy Application

Referees:

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Please provide at least 2 referees/references from the following: your whanau, mental health/social services team or a current or previous landlord