Part A: Personal Details

1. Are you the customer (account holder)?
Yes (fill out 3a)No (Go to Q2)

2. Are you a person listed as an authority on the customer’s account?
Yes (fill out 3a and 3b)No *You must be added as an authority to the customer’s account before you make this application

3a. Details of customer

First name(s):

Preferred first name (if different):

Surname or family name:

Title:
MrMsMrsMissDrOther, please specify
What is the customer/household account number (or equivalent) with the provider?

What is the address receiving phone service?

Telephone:

Mobile:

Email address:

Postal address:

City/Town:

Postcode:

3b. Details of person listed as an authority on the customer’s account

Please only fill out this section if you are not the customer

First name(s):

Preferred first name (if different):

Surname or family name:

Title:
MrMsMrsMissDrOther, please specify
Telephone:

Mobile:

Email address:

Postal address:

City/Town:

Postcode:

4. What is the preferred method of contact (please tick)?
Home phoneMobileMailEmail

5. Are you making this application for yourself, or on behalf of someone else?
I am applying to be covered by the 111 Contact Code (Go to Part B)I am applying on behalf of someone else (fill out 5a)

5a. Details of person who wants to be covered by the 111 Contact Code

Please only fill out this section if you are applying on behalf of someone else

First name(s):

Preferred first name (if different):

Surname or family name:

Salutation:
MrMsMrsMissDrOther, please specify

Part B: Information on the person at particular risk

6. Please select which category most closely relates to the specific circumstance of the person who wants to be covered by the 111 Contact Code?
HealthSafetyDisability
7. Is the specific circumstance of the person permanent or temporary?
PermanentTemporary

If you selected ‘Temporary’, what is the estimated period of time the category of particular risk will apply to the person?

Part C: Supporting information

8. What information is being provided in support of the application?
Sufficient evidence to support that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service (fill in 8a)Details of a nominated person we can contact to verify that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service (fill in 8b and 8c)
8a. Sufficient evidence to support that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service

Please describe the supporting evidence you are providing:

Please attach this supporting evidence to your application.

8b. Details of nominated person

Details of a nominated person we can contact to verify that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service

First name(s):

Surname or family name:

Occupation:

Telephone:

Mobile:

Email address:

Postal address:

City/Town:

Postcode:

8c. Declaration regarding nominated person

Please note that if you are making this application on behalf of someone else, before completing this declaration, you must have received permission from that person to authorise us to contact the nominated person

• I authorise Telesmart Ltd to contact (Full name of nominated person) for the purposes of verifying that I (or the person I am applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service.

Signature:    
Date:              

Part D: General declaration

• I acknowledge and declare that, to the best of my knowledge, the information given in this form is correct;

• I acknowledge and declare that :
  (please insert your name here, or the person you are applying on behalf of)

  • is (or will become) at particular risk of requiring the 111 emergency service; and

  • does not have a means to contact the 111 emergency service at the premises (such as access to a mobile phone) that can be operated for a continuous 8-hour period in the event of a power failure;

• I understand that the information I have provided in this form will be stored with Telesmart Ltd;

• I understand that the information I have provided in this form may be shared with relevant third parties for the purposes of providing and managing my service.

Signature:    
Date: