Host Registration Form

Title *

Full Name*

Date of Birth

Date

Phone Number*

Country code Phone Number

Email

example@example.com

Address*

Street Address

Street Address Line 2

CityCounty

Postcode

Why do you want a Helpful Housemate?*

Please include a summary of the help you require - A housemate can help with things such as shopping, putting bins out, hoovering, unscrewing jars, IT assistance

Short introduction to yourself*

Religious, political views, food allergies, interests and hobbies etc

When is the room available?

Date

Do you have an expected rental figure in mind?

We will discuss with you what rent could be expect

What would be your preferred Helpful Housemate?

FemaleMaleDon't mind

Do you, or any regular visitors, smoke in the house? Please note if the answer is YES a fire extinguisher is mandatory*

YesNo

Do you have any current support within the house or garden?

Eg cleaner, gardener, carer?

Do you have pets?

YesNoVisiting pets

Can a Helpful Housemate bring their own pet?

YesNoMaybe

Is the accommodation within a...

HouseFlatSelf contained within the property

Are you the Householder?

YesNoOther

What type of room is available?

SingleDouble

Please indicate what furniture is in the room, including the bed size?*

* In accordance with Furniture and Furnishings Fire Safety Regulations 1987, any furniture you provide to your Helpful Housemate must be fire safety compliant and carry fire safety labels. This does not apply to furniture made before 1950

Is the bathroom*

SharedOwn ( separate but sole use)Ensuite ( attached to the bedroom)Is there a walk in shower for use?

Kitchen facilities for use

MicrowaveWashing machineDishwasherTumble dryer

Other facilities for use

GardenParkingDining roomSitting room

Is there a burglar alarm?*

Are there working smoke alarms on each floor*

Please note that this is a requirement of having a Helpful Housemate and you will need to install them before they move in and confirm you have done so.

Is your boiler/gas oven serviced annually by a Gas Safe-registered engineer? *

This is a requirement for having a Helpful Housemate. The engineer must provide you with a service report and/or Gas Safety Certificate and a copy must be sent to us.

Are there working carbon monoxide alarm in rooms with a gas boiler or usable fireplace?*

Please note that this is a requirement of having a Helpful Housemate and you will need to install them before they move in and confirm you have done so.

Security

Is there a 5-lever mortice lock on the front door?Are there window locks on the ground floor?

Do you have broadband

YesNo

Council Tax Band*

Next of Kin

Rows	e-mail	Tel no	Relationship to Host
Name

Important Information

Council Tax: Only full-time students are exempt from Council Tax. If you accept a Helpful Housemate who is not a student and claim single person discount on your council tax you will lose your single persons discount. To compensate for this loss you can ask non-excempt Helpful Housemates to make a small contribution to your council tax, to assist you with the loss of your single persons discount. This must be discussed in advance when setting the level of rent.

Home insurance: Please contact your Household Insurance company to ensure that your home insurance remains valid if you have a Helpful Housemate (lodger)

Advertising protocal: Please note any photographs you provide may be used to support advertising for a suitable Housemate. Please note that we take every effort not to use phtographs that could identify the person or the specific location.

We will hold information provided and this information will be used in accordance with Helpful Housemates privacy policy.

Signature

Picture of bedroom

Picture of bathroom

Picture of kitchen

Proof of your address

Assigned to

Client Type

Type

Date