REFERRAL FORM
Referring Agency Details
Agency Name:-
Contact:-
Address:-
Office Telephone No:-
Post Code:-
Mobile Telephone No:-
Date:1.
2.
/
/
Signed:-
Have you seen clients proof of benefit?
YES / NO*
1.1. If yes which benefit
_________________________________________
1.2. If no, please explain
_________________________________________
Have you made the client aware that there are charges to be paid for delivery
YES / NO*
2.1. Who will be paying the delivery charge?
Agency / Client*
2.2. Have you made the client aware that delivery charges must be paid before
the items can be delivered?
YES / NO*
Agency please make client aware that payment should be chip and pin or cash. Clients receiving means tested benefit may receive
up to 50% discount on essential items. There is a delivery charge of between £12 and £18 in the Epping Forest District regardless of
how many items are purchased. White goods are not currently discounted due to limited supply and cost to test and repair. Goods are
purchased ‘as seen’ and customers are asked to check their suitability prior to purchase. Lighthouse Furniture Project trading as
Epping Forest Reuse cannot be held responsible or liable for any damage, loss or injury to any item or person howsoever caused by
the items purchased from us. This does not affect your statutory rights.
3.
5.
Have you made the client aware that there are charges to be paid for items?
3.1. Who will be paying for the items?
Has customer requested help from the Essential Living Fund?
Clients Name:-
YES / NO*
Agency / Client**
YES/NO*
*Delete as applicable
New Address if moving to new property and date of move:-
Current Address:I understand that there may be charges as detailed in 2 &
3 above.
Client Signature:-
Post Code
Telephone No:Mobile Telephone No:-
Items required (see list of items covered by the project)
Please note that we do not supply gas heaters or items that do not comply with fire regulations
For use by Epping Forest ReUse
Date received by EFR
/
Actioned By:- __________________
/
Internal Referral Reference Number
___________________
Working in Partnership with
Lighthouse Furniture Project Ltd
Company Limited by Guarantee in England and Wales No. 05249004Registered Charity 1120398
Not For Profit Company serving the community
Member of the Furniture Re-use Network