Who requires the following furniture to help furnish the above address:-

ITEMS REQUIRED	DATE COLLECTED	ITEMS REQUIRED	DATE COLLECTED

A contribution towards each item will be expected on collection and will be made by...(tick appropriate box):

Referring Agency (please indicate maximum allowance)

The person recieving the furniture

Referring Agency:	__________________________________________
Referring officer	__________________________________________
Telephone Number	__________________________________________

I can confirm that the referral meets the criteria for the project.

Signed	_____________________________________
Dated	_____________________________________

This form is valid for 6 weeks from the date of referral and can be sent or faxed to Dorset Reclaim in advance of your visit or brought with you when you call.
If possible bring transport with you on the day of your visit. Dorset Reclaim offer a delivery service at nominal cost, although there may be a delay between your visit and us being able to make delivery to you.