1 Start 2 Complete Are you: * The Customer A Family Member or Friend Organisation/Agency/Service Provider If you are making this request for someone else, please provide your details here: Only complete this short section if you are NOT the customer. If you are the customer, please move on to the 'CUSTOMER' section below. Name Email Organisation/Agency/Service Provider/ or relationship to the customer (if applicable) If you are referring someone else, are they aware that you are contacting us? Yes No CUSTOMER Customer's Name * Customer's Address * Customer's Postcode * Customer's Telephone/Mobile Number * Customer's Email Address (if available) Customer's Date of Birth (dd/mm/yyyy) * Haringey Circle Member? * Yes No Don't Know CHOOSE SERVICE (only one service per request) * Gardening Service Handy Person Service Home Help - Cleaning and Domestic Support Service Home Help Service (please choose) Cleaning Tidying up Washing up Laundry Ironing Window cleaning (inside only) All of the above Other (please provide details below) Gardening Service (please choose) Fence/Gate Repair (small scale) Hedge Trimming Lawn Mowing Painting/Creosoting Shed/Fence/Gate Planting (small scale) Tidying Up Garden Weeding Other (please provide details below) Handy Person Service (please choose) Assembling Flat Packed Furniture Fitting Door Chain/Lock/Spyhole Draft Proofing Doors Installing Grab Rails/Key Safe Installing Smoke/Carbon Monoxide Detector Painting/Decorating (one room) Repairing/Replacing Leaking Tap Replacing Toilet Seat Taking Down/Putting Up Curtains/Shelves Unblocking Sink Window/Gutter Cleaning (up to first floor level) Other (please provide details below) PAYMENT One of our team will contact you to arrange payment. Payment method * Debit Card Direct Debit (for on-going services) Cheque COVID-19 Requirements Our staff are trained to work safely and will wear the appropriate level of Personal Protective Equipment (PPE). We comply with all Government requirements relating to safe working practices. You must inform us if any member of your household has tested positive for COVID-19 and is in self-isolation. Are there any other issues that we should be informed of? CONSENT By submitting this form, you consent to us contacting you and storing the information provided on our secure database. * Tick here to provide your consent. Submit
