Application for Assisted Collection

Mayrise Ticket………………

This application should be completed with the details of the Assisted person/s.

Please complete all sections that apply.

1APPLICANT’S DETAILS

Last Name: / Circle as appropriate
Mr / Mrs / Miss / Ms / Other
First Name: / Also Known as:
Address: /
/ Date of Birth:
Post Code: / Contact Telephone Number:
E-mail address:

Previous address (if different in last 3 years) Note you must notify the Council of an change of address.

2.REASON FOR APPLYING

If there is an able person at the address who can move the bins and boxes then the property will not qualify for an assisted collection.

Please provide a COPY of any up-to-date medical evidence that supports your application* For example,

prescription list, appointment cards, etc. If you are a Blue Badge holder ( disabled parking permit)) who lives alone with no able person living at the address YOU ARE NOT REQUIRED to submit any further evidence nor answer questions b to g.

a)Blue Badge Number:
b)Is your disability permanent? YES NO
c)If no, please give details.
d) Are you registered blind under the National Assistance Act 1948? YES NO
e) Do you use a wheelchair? YES NO
f) Are there any able bodied person/s residing at the property? YES NO
g) If YES please give details.

3.MEDICAL INFORMATION

Please provide details of your doctor. If there is someone we can contact who can give more information about your disability please give details. It could be your doctor or nurse, occupational therapist, social worker, hospital consultant etc:

Name of Doctor/Nurse/Social Worker etc:
Address:
Telephone Number: E-mail Address:

4.DECLARATION – TO BE COMPLETED BY ALL APPLICANTS

I declare that the statements I have made on this form are a true and accurate record of my circumstances.

Signed: / Date:
  1. APPROVAL OF ASSISTED APPLICATION

If the Council does not contact you, then it will have been approved by the Waste department. (within 10 days).

6.PLEASE NOTE YOU ARE RESPONSIBLE FOR NOTIFYING THE COUNCIL OF ANY CHANGES TO YOUR CIRCUMSTANCES

* Evidence can be posted with your application or taken to the Customer Access Point, Municipal Offices, Grimsby or to Customer Access Point Immingham Civic Centre Community Hub with your application.

OR PLEASE POST TO:Waste Operations, Gilbey Road Depot, Estuary Way, Grimsby, North East Lincolnshire, DN31 2UD