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Request to continue with the water planning programme

If you would like to continue participating in this programme, please complete this form.

We’ll contact you to welcome you and send you gift vouchers as a thank you.

If you have any questions or have difficulty filling in the form please contact us on 0345 601 3075 (local rate) or email us.

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Name: *

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Tel. no: *

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Email: *

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Property Reference or House Number:

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Postcode: *

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Date that you moved into the property: *

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Number of appliances: Add number

Automatic washing machine

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Twin-tub washing machine

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Single-tub washing machine

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Dishwasher

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Water softener

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Waste disposal unit

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Age: (Indicate total number of people)

0 – 2

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3 – 5

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6 – 10

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11 – 15

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16 – 17

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18 – 24

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25 – 34

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35 – 44

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45 – 54

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55 – 59

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60 – 64

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65 +

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Occupancy: (Number of people)

Permanently living there

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Living there weekdays only

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Living there weekends only

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Living there term time only

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Living there term break only

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Employment and education: (Number of people)

Work (full time)

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Work (part time: 8-29 hrs)

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Work (part time: Up to 8 hrs)

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Housewife/house husband

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Retired

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Unemployed

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Full time further education

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School

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Pre-school

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Other

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Occupancy type: *

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Any special needs that we should be aware of (e.g. disabled, home kidney dialysis, etc)

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Please tick the box if: *

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Phone

Emergencies (24hrs)

Email

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