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Disabled facilities adaptation / Grant enquiry form

Please complete the details below and an enquiry pack will be forwarded to you.

You can either complete the form on line and submit or alternatively print off and return to:

The Disability team
Regeneration Unit
154 – 162 Blackburn Road
Bolton
BL! 8DR

Householders name:
Address of property:
Postcode:
Email address:
Telephone (day time):
Contact Address (if different from property address):
Telephone (if different):
Is this property:		Bolton at Home tenant Owner occupied Other private housing Housing Association Please specify:
Status:		Couple Lone parent Single
Ethnicity monitor:		White: British Irish Any other white background Please specify: Mixed: White and black Caribbean White and black African White and black Asian Any other mixed background Please specify: Asian or Asian British: Indian Pakistani Bangladeshi Any other Asian background Please specify: Black or Black British : Caribbean African Any other black background Please specify: Chinese

Name of disabled person:
Date of Birth (dd/mm/yyyy):

For office use only
Pack sent:
Ref area:
Gin no:
Enquiry taken by:
Telephone:
Date: