Assisted Refuse / Recycling Collection Form To see more about how we record and store your information please see the Council’s privacy notice. Step 1 of 5 20% Please Note: The Council will provide, upon application, an assisted collection to those residents who can demonstrate that infirmity or disability prevents them being capable of moving their waste receptacle(s) to the Council's designated collection point. The assisted collection will only be provided if there are no other able bodied people living in the household over the age of 12 who are capable of presenting the containers. In such cases the collection of household waste and recyclables will be made from an agreed point and returned once emptied. Residents living in terraced properties in receipt of an assisted collection will need to put their house number on their back gate. Save and Continue Later Your DetailsName* First Last Address* Street Address City State Zip/ Postal Code PhoneEmail Assistance RequiredAssistance requested for:* Wheeled Bins Recycling Containers Save and Continue Later Household Members DetailsList of Members*Please click on (+) button to add more members Full NameDate of Birth Do any of the relatives live near by who could help you present your containers?*YesNoDo you have a neighbour who could help you present your containers?*YesNoDo you have a carer who could help you present your containers?*YesNoPlease state reason why you require assistance?*OAPDue to a disability Save and Continue Later Statement Please read the following statement and then confirm by answering question below it. I confirm that I am incapable of presenting my refuse/recycling containers at the required collection point. I agree to inform the Council immediately if my circumstances change and I am no longer in need of the assisted collection service. I understand that the Council reserves the right to remove the above property from its assisted collection list should my circumstances change and / or any family member residing at the property is found to be capable of presenting the refuse/recycling containers at the required collection point. Please note: If your request for assistance is granted, an identification sticker will be placed on the front of your wheeled bin. Your bin will also need to be sited so that our collection crews can easily see the sticker making them aware that assistance is required. If your request for assistance is unsuccessful then we will inform you by telephone within 5 working days. We also offer smaller wheeled bins, which are easier to handle for refuse collection and blue bags with handles for recycling for those who still wish to present their own containers. If you wish to swap any of your containers please ring our Customer Services on Tel: 01254 388 111 or email at email@example.com Do you agree with the statement above ?*AgreeDisagree Save and Continue Later By pressing "Submit Form" button below would complete this form and send it for internal processing. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.