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Required Information *
:: ONLINE FORM ::
Referral Form for Agencies / Organisations / Authorities
Depot
Please select
the relevant Depot
*
Bournemouth Depot
Poole Depot
Dorchester Depot
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Organisation / Agency Information
Referring Organisation
*
Referring Officer
*
Address & Postcode
*
Telephone Number
*
E-mail
*
NB: Please make sure to enter your email address accurately
as this is where the confirmation will be sent to.
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Your Client's Information
Client's Name
*
Address
*
Postcode
*
Area
(if applicable)
ie: Winton (for Bournemouth) ;
Alderney (for Poole) ; Bridport (for Dorchester)
Telephone Number
*
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Purchase Information
Required Items
*
Please state maximum value per item, if relevant
Will the Client Need?
(optional)
Washing Machine Connection
Electric Cooker Connection
Delivery (Charged at £15)
Who will be responsible
for Payment
*
Organisation / Agency
Client
Jointly
Maximum Allowance (£)
*
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Extra Information
Anything else you wish to tell us?
Please enter the word.
(If reading it is difficult, simply click on the little arrow for a different word)
*
::
Submit the information
::
Should be Empty:
Note
(1)
:
You may click "back" within the form without losing the information you have entered.
Note
(2)
:
A copy of your submission will be sent to your email.
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