Online order form
Step 1: How many people do you want to call?
2 people
4 people
8 people
Step 2: Enter the names and numbers of the people
you want to call.
Do you want 999 as one of your contacts?
Yes. Please leave line 1 as is and write your first contact on line 2.
Note: 999 will count as one of the 2, 4 or 8 allocated contacts.
No. Please write your first contact and their number over the
‘999’ in line 1.
Name
1. 9 9 9
2. 3. 4. 5. 6. 7. 8. Phone number
9 9 9
Step 3: Pick the design you want and tick the box.
Blue
Green
Orange
Purple
Pink
Sky
Rain drops
Autumn
leaves
Crocus
Roses
Standard
Step 4: Choose a plan and enter your payment details.
Talk plans (please tick the monthly airtime plan you would like)
Plan 1
£7.50 per month
50 minutes of calls
Plan 2
£10.00 per month
100 minutes of calls
Plan 3
£15.00 per month
500 minutes of calls
Gift Package
£87.50 one off payment
50 minutes of calls per month
for 6 months
Direct Debit
Your monthly airtime plan will be paid by Direct Debit.
Please enter details below.
Name(s) of Account Holder(s):
Bank or Building Society Account Number Branch Sort Code Signature:Date:
Handset Purchase
Card details
(£55 will be charged for the Age UK My Phone handset and delivery)
Name on card:
I wish to pay by (please tick)
Mastercard
Visa
Maestro
Issue Number Card Number Expire date Security number Signature:Date:
(Maestro only)
Step 5: Contact and Delivery Details
Contact Details
(please tick the box that best describes payment and user contact details)
The Age UK My Phone is for me (fill out section 1 only)
The Age UK My Phone is for someone else (fill out section 1 and 2)
Section 1
Name and billing address (for paying the monthly plan)
Title:Name:
Address:
Postcode:
Tel:
Email:
Section 2
User name and address (contact details of person using the phone)
Title:Name:
Address:
Postcode:
Tel:
Email:
By providing your email address and phone number you are agreeing to receiving information
from us about our other products and services that may be of interest to you and the vital work
Age UK undertakes for people in later life, unless you indicate otherwise by ticking this box
‘Us/our’ includes CyCell Limited and Age UK, which for the purposes of data protection
includes Age UK charity (registered charity number: 1128267) and its group of companies and
National Partners (Age Cymru, Age Scotland and Age NI). CyCell Limited and Age UK will use
the information you have supplied above to communicate with you in accordance with Data
Protection guidelines.
GPDT12XX21Z001
Step 5: Contact and Delivery Details cont.
Delivery Details
Please supply contact and delivery details of where and to whom
the Age UK My Phone should be shipped to.
Same as Section 1
Same as Section 2
Different contact and delivery address from Section 1 and 2
(fill out details below)
Name:
Address:
Postcode:
Tel:
Email:
Step 6: Further information (optional)
It would be helpful to know how you came to know about
the Age UK My Phone. Please tick the box that best applies.
Internet
Which website?
Ad, newspaper article, magazine Which one?
Word of mouth
Received a leaflet
Other:
Age UK shop