Customers Care Registration Form

If you, a relative or friend would like to take advantage of any of our special services, we would ask you to complete this special needs registration.

If you are registering on behalf of a relative or friend, please ensure to use their details.

Customer Details
   
Name:
Address:
 
 
Postcode:
Home Tel No:
Work Tel. No:
Customer Number:
E Mail Address:
   
Doorstep Service
 
Please tell us about your disability. (Please tick)
 
Hearing: Talking Bill
Mobility: Large Print Bill:
Speech: Braille Bill
Sight:    
Other: (please give details)  
 
   
Are there any senior citizens at home? Yes  No 
   

Password Scheme
   
I would like my password to be (No more than 8 letters)  
 
Carers Contact Service
 
Name of Carer :
   
Address:
 
 
Postcode:
Home Tel No:
Work Tel. No:
   
 

 


 

 
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