Application for Donation of Furniture

Application for Donation of Furniture
(This information will be treated in strict confidence)
Title*
Full Name*
Address*

Street Address

Street Address Line 2

Town/CityCounty

Post Code
Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Your Date of Birth

DayMonthYear
Date
Your Place of Birth
How long have you lived in North East Lincolnshire
Your National Insurance No
Do you receive income from paid work?*

YesNo
Name of Partner
Partner’s Date of Birth

DayMonthYear
Date
Partner’s Place of Birth
How long has your partner lived in North East Lincolnshire?
Partner's National Insurance No
Does your partner receive income from paid work?

YesNo
Date you moved into or intend to move into your property

DayMonthYear
Date
How did you hear about CARE?

Names and ages of all dependent children who live with you:

	Name	Age
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6

Have you received help from the CARE shop before?

YesNo
If the CARE shop has helped you before, please give details
Is your home (please indicate)*

OwnedRented from a private landlordRented from an housing associationOther
What items of furniture are absolutely necessary and how urgent is the need:

	Necessary Item of Furniture	How Urgent is the need?
1
2
3
4
5
6
7
8
9
10
11
12

Please explain the reasons that have lead to this need arising: i.e: the story leading up to your present circumstances
Please give details of your financial situation:
Do you have any savings?

YesNo
Amount and types of state benefit*
Amount of Local Housing Allowance (Housing Benefit)?
Amount of Rent?
Income from your paid work?
Income from your partner's paid work?
Are you being supported by Social Services or any other organisations?
Have you applied to the Social Fund, if so do you have evidence of a decision?
Have you received help from any other furniture recycling company?
If yes please give details of furniture you received and where from
Is there anything else you may wish to tell us that you feel may be relevant?
PLEASE SIGN AND DATE THIS FORM AND RETURN IT: THE CARE SHOP, 46/47 ALEXANDRA ROAD, CLEETHORPES, DN35 8LE, OR EMAIL TO: shop@carenelincs.co.uk
Signature

Clear
Date

DayMonthYear
Date
Equal Opportunities Monitoring Form

We keep records of people who apply to us for support. This is to ensure that our service is provided on an equal basis without discrimination on the grounds of age, gender, race, ethnicity, sexuality, disability or religion. Any information you choose to give us will be treated in confidence and will be used for monitoring purposes only.

We keep records of people who apply to us for support. This is to ensure that our service is provided on an equal basis without discrimination on the grounds of age, gender, race, ethnicity, sexuality, disability or religion. Any information you choose to give us will be treated in confidence and will be used for monitoring purposes only.
GENDER

MaleFemaleOther
AGE

under1818-2425-2930-3435-3940-4950-5960-6970 +
RACE:

WhiteBlackAsianMixedOther
ETHNICITY:

BritishIrishAny other White backgroundAfricanCaribbeanAny other Black backgroundBangladeshiIndianPakistaniArabChineseAny other Asian backgroundWhite & AsianWhite & Black AfricanWhite & Black CaribbeanAny other Mixed backgroundGypsyRomanyTravellerPrefer not to say
Sexual Orientation

BisexualGayHeterosexualLesbianPrefer not to say
DISABILITY: If yes, please tick the relevant box:

YesNoDon't knowMobilityVisual ImpairmentHearing ImpairmentMental Health ConditionAutistic Spectrum ConditionLearning DisabilityProgressive Disability Chronic IllnessOther
RELIGION

BuddhistHinduSikhMuslimJewishChristianPrefer not to sayNot knownNoneOther
MARRITAL STATUS:

SingleMarriedSeparatedDivorcedLiving with PartnerOther
Thank you for taking the time to provide this information.
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Application for Donation of Furniture

What items of furniture are absolutely necessary and how urgent is the need:

PLEASE SIGN AND DATE THIS FORM AND RETURN IT: THE CARE SHOP, 46/47 ALEXANDRA ROAD, CLEETHORPES, DN35 8LE, OR EMAIL TO: shop@carenelincs.co.uk