ASSISTED GARDEN MAINTENANCE APPLICATION FORM

Name:  ..........................................................................................................................................

Address: ......................................................................................................................................

Tel No: ..........................................................................................................................................

Email Address: ...........................................................................................................................

Age:  	......................................

Details of disability (if relevant) .................................................................................................

.......................................................................................................................................................
Work required:
						Front     Back
	Grass Cutting				    
	Hedge Trimming			    

There is a weekly charge of £4.61 with effect from 7 April 2014.  There is a maximum of 200 places on the list for tenants who pay the charge, and the list for tenants exempt from the charge is closed.  Therefore you may be placed on a waiting list until a space becomes available.  In order to qualify for a place on the list you have to meet the following criteria and agree to pay the weekly charge.

Do you live alone and have no-one in the district or locality who is able to maintain your garden, and	YES/NO	
Are you in receipt of Disability Living Allowance or Attendance Allowance, and
(if yes, please provide proof of your benefits)	YES/NO	
Do you live in the Council's "elderly designated accommodation" eg: a bungalow	YES/NO	

I agree to pay the weekly service charge.  This sum may change annually subject to contract costs.

I understand that if there are arrears on my account the service will be withdrawn and once arrears are cleared I will be placed on a waiting list for reinstatement.

Signed	Tenant 1  ...........................................................   Date  .................................

		Tenant 2  ...........................................................   Date  ..................................

Equal Opportunities

We want to make sure our services are available to the people that need them, whatever their race, colour or national origin.  The information you give here will help us do this.  What you tell us will not affect your application and you do not have to give us this information.

	Application	Joint Application	
A	White			
	British			
	Irish			
	Any other White background			
				
B	Mixed			
	White & Black Caribbean			
	White and Black African			
	White and Asian			
	Any other Mixed background			
				
C	Asian or Asian British			
	Indian			
	Pakistani			
	Bangladeshi			
	Any other Asian background			
				
D	Black or Black British			
	Caribbean			
	African			
	Any other Black background			
				
E	Gypsy/Romany/Irish Traveller			
				
F	Chinese or other ethnic group			
	Chinese			
	Any other			
				
G	Sexual Orientation			
	Bisexual			
	Heterosexual			
	Homosexual			
	Do not wish to answer			
				
H	Religion			
	Baha'i			
	Buddhist			
	Christian			
	Hindu			
	Jain			
	Jewish			
	Muslim			
	Sikh			
	Zoroastrian			
	Other			
	None			
	Do not wish to answer