About You Reference Number
Name
Address
Please 'check' the relevant boxes below
Do you have problems with your sight?
Do you have problems with your hearing?
Do you have problems getting about or do you have a serious illness?
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?
If yes what is your telephone number?
Large Print: would you like us to send out your documentation in large Print
Braille: Would you like us to send out your documentation in Braille?
Textphone (minicom): Would you like to contact us on our textphone and us to contact you on your textphone?
If yes what is your textphone number?
Nominee Scheme: Would you like us to send all your documentation to a friend or relative (Please make sure you check with them before you give their details to us)
Nominees name and address:
Information supplied by—
• Your name
Your Email address
Telephone number (including STD, please leave out brackets)
Data protection Act 1998—relevant information given in this form may be disclosed to the Council's Benefits Service or to other council departments.
