Repair Request Form

Your details: Name: Address: Town: Post Code: Telephone: Email: What type of repair is required? plumbing electrical joinery central heating not sure glazing bricklaying roofing drain Description:    please describe the fault as fully as possible. Where is the fault located? Kitchen Living Room Dining Room Hall / Staircase Bathroom G. Floor WC G. Floor Bathroom F. Floor WC F. Floor Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 External (Front) External (Rear) External (Side) Out Building / Yard Other Location Please state: Appointment Preferences We will try to arrange an appointment for your repair to be either inspected or carried out, whichever is appropriate, at a time convenient to you. Please indicate your preferences below. Monday AM   PM   Tuesday AM   PM   Wednesday AM   PM   Thursday AM   PM   Friday AM   PM   Between the following dates: Beginning: Ending: Personal Information We are working towards a policy of ensuring that we provide services fairly whatever a person's age, disability, race, colour or ethnic origin. Please give the following information. We'll use it to check that all our customers receive a fair service. All the information you provide will be held in confidence. It will not be released to others without your written agreement. Your gender Male Female Disability Do you have a physical disability? Yes No Your age 16-25 26-40 41-59 60-74 75 or over Your ethnic origin White White British White Irish White other Asian or Asian British Indian Pakistani Bangladeshi Asian other Black or Black British Caribbean African Black other Mixed White & Black Caribbean White & Black African White & Asian Other mixed Other ethnic group Chinese Any other ethnic group