Title         Mr Mrs Miss Sir Dr Ms Other         First Name 

Surname 

Date of Birth    01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December Year         Marital Status  Married Single With Partner Divorced Widowed

 Address   

     Town             County 

Post Code     How Long Have You Been at This Address 
                                                                                                                                                               (please state in Years and Months)

Previous Address (if Less Than 3 Years)

   Address 

      Town             County   

Post Code      How Long Were You at This Address 
                                                                                                               (please state in Years and Months)

Phone Numbers:  Day    Evening     

              Email Address

Are you on the Voters Electoral Role  -- Yes No

Employers Name    

Employers Address 

                         Town     County    

                 Post Code 

         Phone Number             Your Job Title 

How Long Have You Worked Here 
                                                                             (please state in Years and Months)

Name of Bank or Building Society   

      Type of Account (please state)  Eg Current or Deposit

Credit Cards Held:  Visa     Mastercard     Amex     Diners   
  
                        Others (please state)

Do you have Household Contents Insurance     ----- Yes No

If Yes, Which Company? (please state) 

Do you currently rent any electrical equipment?  ------ Yes No     

If Yes, Which Company do you rent from?  

How Long have you been with them?  (please state years and months) 

     What Type of Equipment Rented? 

I would like to Order:

Please treat this as an order    Just treat this as an enquiry at this stage

The above information given is true and accurate to the best of my knowledge.
I understand that by completing this form a credit search may be carried out.     Please tick

Weekly prices quoted through these web pages are payable monthly by standing order.

e.g. £3 weekly = £13 per month.  (Weekly x 52 divided by 12).   Offered subject to status, to persons over 18 years.  Minimum contract period 17 months.  One month payable in advance.  Written quotations available on request.

Completion of this form does not confirm the supply of equipment.
The offer is made subject to satisfactory status and credit clearance.