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Tuesday, 09-Mar-2010
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New household registration
New household registration
New household registration
Details
Applicant Details
Title:*
**Please Choose**
Dr
Miss
Mr
Mrs
Ms
Other
First name:*
Family name:*
Address 1:*
Address 2:*
Address 3:
Address 4:
Postcode:*
Date moved in to this address:*
(dd/mm/yyyy)
Home telephone:
Work telephone:
Mobile telephone:
Email:
National Insurance Number:
Date of birth:*
(dd/mm/yyyy)
Gender:*
**Please Choose**
Female
Male
Ethnic Origin:*
**Please Choose**
Asian Bangladeshi
Asian Indian
Asian Any Other
Asian Pakistani
Black African
Black Caribbean
Black Any Other
Chinese
Mixed W & B African
Mixed W&B Carribean
Mixed W & B Asian
Mixed Other
Other Ethnic
White British
White Irish
White Any Other
Unavailable
Other
Is this household member pregnant?
yes
no
If yes, when is the baby due?
(dd/mm/yyyy)
The Disability Discrimination Act (1995) DDA defines a person as disabled if they have 'a physical or mental impairment which has substantial and long term adverse effect on their ability to carry out normal day to day activities'.
Do you consider yourself to have a disability as defined by the DDA?
**Please Choose**
No
Yes
Your religion:
**Please Choose**
Buddhist
Other
Jewish
Muslim
No Religion
Christian
Hindu
Sikh
Your sexual orientation:
**Please Choose**
Gay
Not provided
Transgender
Bisexual
Heterosexual
Lesbian
Prefer not to say
Has this applicant been known by any other names, eg a maiden name - if so, please provide details:
Which language does this applicant prefer using?
**Please Choose**
French
Somalian
Urdu
Polish
Arabic
Hindi
English
Kurdish
Punjabi
Does this household member require an interpreter?
yes
no
Is this applicant moving from abroad?
yes
no
If yes, for what reason?
**Please Choose**
a. EEA worker
c. Self employed
d. Persons granted refugee status
f. Indefinite Leave to Remain/enter the UK
g. Other
Nationality:
**Please Choose**
Czech Republic
Estonia
Hungary
Latvia
Lithuania
Non-EEA national
Other EEA national
Polish
Slovakia
Slovenia
UK national
Other details:
Child access:
yes
no
Child access details:
School details:
GP details:
Job title:
Employer's name:
Employer's address:
Income:
Current landlord
Which Local Authority area do you want to live in:*
**Please Choose**
Derby
South Derbyshire
Contact address
Name:*
Same address as main applicant:
yes
no
If yes, then please ignore the following address fields
Address line 1:*
Address line 2:*
Address line 3:
Address line 4:
Postcode:*
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