Request a starter pack

    Agency information

    Date of Referral (required)

    Referring Agency (required)

    Name of Agency Representative (required)

    Agency Address (required)

    Agency Contact Number (required)

    Agency E-Mail Address (required)

    Client Details

    Client Name (required)

    Client Age Range

    Client Address (required)

    Date of Tenancy

    Client Contact Number

    Do your require a Starter Pack?(required)
    YesNo

    Starter Pack Information

    Delivery Location (required)

    Number of Adults

    If other, please specify here

    Please list how many children under 16 you have. List gender and age

    What bedding is required? Limit one per family member

    Double Bed

    Single Bed

    Child's Bed

    Do you require curtains? Please check the required sizes
    W46in L54inW66in L54inW46in L72inW66in L72in

    Number of pairs of curtains required

    Additional Information (We are sometimes able to offer kettles, toasters and slow cookers. Please state if the client would be interested in receiving these if available)

    I confirm that the information provided above is accurate to the best of my knowledge

    To comply with data protection regulations (2018), we are unable to store and use your information unless you give us your permission. Please select Yes to allow this or we will be unable to process your referral. View our Privacy and Data Policy for full details.

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