Application for additional services

Personal details:

Name

Telephone

Supply address:

Address

County

Postcode

Billing details:

Billing reference [?]

Your billing reference number is located on the bottom of your bill, in the place of the highlighted area shown below: how to find your billing reference

Additional information:

Are you, or anyone who lives with you, blind or have difficulty with sight?

Are you, or anyone who lives with you, deaf or have difficulty with learning?

Do you, or anyone who lives with you, have a physical disbility which restricts your movement?

Please state the disability

Do you, or anyone who lives with you, require kidney dialysis at home?

Do you, or anyone who lives with you, require a constant water supply?

Please give details

Additional services:

I wish to join the Password scheme

My choice of password is :

I wish to join the Redirection of Callers Service

The person who has agreed to check the identification of callers on my behalf is:
Name

Address

Postcode

I wish to join the Redirection of Bills Service

The person who has agreed to receive bills on my behalf is:
Name

Address

Postcode

I wish to receive my bills on audio cassette

I wish to receive my bills in Braille

I wish to receive my bills in large print

I am registered physically disabled, and would like you to contact me to discuss having my meter re-sited

If you have hearing difficulties and would find it difficult to to hear the message given out with a loudhailer in an emergency, would you like us to:
Visit you?
Put a card through your letter box?

If you would like any of our information audio cassettes, please choose below:
Additional services
Should I have a water meter
How we handle your complaints
Code of practice for the collection of unpaid charges from household customers

Declaration

I agree that the information provided in this application form may be held and used by Dee Valley Water (and its authorised employees and agents) to provide the services I have applied for.