A7 Contact details Telephone Landline <Fill in landline number> Mobile <Fill in mobile number> Email address <Fill in email address> A8 Do you require an interpreter when speaking with us? This includes interpreters for languages other than English, and for people who have a hearing or speech impairment. (Mark with an as applicable) ‘X’ No If no, go to Section B Yes If yes, what is your preferred language? <Fill in preferred language> A9 Is the person with the special housing requirements a participant of the National Disability Insurance Scheme (NDIS)? No Yes If yes, please provide the contact details of your NDIS support provider <Fill in the contact details of your NDIS support provider> Declaration, acknowledgement and consent by applicant This section is to be completed by the person applying for special housing requirements. I declare that all the information requested in this application for special housing requirements has been provided, and is true and correct. I acknowledge that I must advise the Department of Health and Human Services if my circumstances change and update the department with any details that are relevant to my application. I authorise the Director of Housing, or officers acting on behalf of the Director of Housing to confirm information concerning this application with people and organisations I have previously nominated, including if applicable, the treating health practitioner that has completed Sections B, C and D of this application. WARNING: If you wilfully give information that is untrue in this application, you may be liable to penalties under section 40 of the Housing Act 1983 (VIC). Full name of applicant <Fill in the full name of applicant> Signature of applicant < (Please sign by hand)> Date <Fill in the date> STOP This section should only be completed by the health practitioner, support worker or other relevant – professional that is relevant to the special housing requirement(s) being requested. Section B Treating health practitioner details – This section should only be completed by the treating health practitioner relevant to the special housing requirement.
A7 Contact details Telephone Landline <Fill in landline number> Mobile <Fill in mobile number> Email address <Fill in email address> A8 Do you require an interpreter when speaking with us? This includes interpreters for languages other than English, and for people who have a hearing or speech impairment. (Mark with an ‘X’ as applicable) No If no, go to Section B Yes If yes, what is your preferred language? <Fill in preferred language> A9 Is the person with the special housing requirements a participant of the National Disability Insurance Scheme (NDIS)? No Yes If yes, please provide the contact details of your NDIS support provider <Fill in the contact details of your NDIS support provider> Declaration, acknowledgement and consent by applicant This section is to be completed by the person applying for special housing requirements. I declare that all the information requested in this application for special housing requirements has been provided, and is true and correct. I acknowledge that I must advise the Department of Health and Human Services if my circumstances change and update the department with any details that are relevant to my application. I authorise the Director of Housing, or officers acting on behalf of the Director of Housing to confirm information concerning this application with people and organisations I have previously nominated, including if applicable, the treating health practitioner that has completed Sections B, C and D of this application. WARNING: If you wilfully give information that is untrue in this application, you may be liable to penalties under section 40 of the Housing Act 1983 (VIC). Full name of applicant <Fill in the full name of applicant> Signature of applicant < (Please sign by hand)> Date <Fill in the date> STOP – This section should only be completed by the health practitioner, support worker or other relevant professional that is relevant to the special housing requirement(s) being requested. Section B – Treating health practitioner details This section should only be completed by the treating health practitioner relevant to the special housing requirement.