About you

Reference Number

Name

Address

Please tick the relevant boxes below

Do you have problems with your sight?
Yes
No

Do you have problems with your hearing?
Yes
No

Do you have problems getting about or do you have a serious illness?
Yes
No

Is there anything else you think we should know?

Please indicate which of our services you wish to register for:

Talking Bills:
would you like us to phone you with details of your bill before we send it to you?
Yes
No

If yes what is your telephone number?

Large Print:
Would you like us to send out your documentation in large print?
Yes
No

Braille:
Would you like us to send out your documentation in Braille?
Yes
No

Textphone (minicom):
Would you like to contact us on our textphone and us to contact you on your textphone?
Yes
No

If yes what is your textphone number?

Nominee Scheme: 
Would you like us to send all your documentation to a friend or relative
Yes
No

(Please make sure you check with them before you give their details to us)

Nominees name

Nominees address

Information supplied by

Your name

Your email address

Telephone number (including STD)

Data Protection Act 1998: relevant information given in this form may be disclosed to the council's Benefits Service, or to other council departments.