APPLICATION FORM

The charity Brick by Brick provides accommodation for the homeless on a semi-permanent and permanent basis.

Find out what to do if you are worried about becoming homeless.
Contact your council: You can apply to the council for help as a homeless person

How to get into a hostel or nightshelter

How can you get into a hostel, nightshelter or women’s refuge if you are single and facing a night on the streets?

To use the following form, please fill it out and click submit button at the bottom.

Name*
Title First Middle Last
Male/Female
- Male
- Female
Date of Birth
Phone
Email
Current address (if homeless, contact address)
Current Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Details of the people the applicant would like to live with:
Name of 1st person
Title First Last
1st person
Relationship
Male/Female
- Male
- Female
Date of Birth
------------------------------------------------------------------------------------------
Name of 2nd person
Title First Last
2nd person
Relationship
Male/Female
- Male
- Female
Date of Birth
Identity Check documents of applicants
DOCUMENT | REFERENCE NUMBER:
Passport
Birth Certificate
Driving Licence
Immigration Document
Immigration check
Immigration Status:
Date of next interview:
References 1
References 2
Property size to be allocated (depending on No. of occupants)
- Single bedroom
- Double bedroom
- Studio flat
- 1 Bedroom flat
- 2 Bedroom flat

Brick by Brick Ethnic Monitoring Form

White

Dual or blended heritage

Asian, or Asian British

Black or Black British

Chinese

Name

This field is for validation purposes and should be left unchanged.