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Application for the supply of SeniorSafety products

This service is for people who meet the following criteria:

  • Aged over 60
  • Savings under £20,000 (including shares, bonds, etc)

Please fill in the form below to apply.

Please note if you have previously referred a client via this form, in the Proposer section of this form you will only need to provide first name, surname and email.

Fields marked with * are required.

1.Proposer

 


2. Client



3. Accomodation




4. Gender


5. Age

6. Products









Data Protection Act 1998
Help the Aged is a registered charity (No. 272786). The data provided here will be used by Help the Aged for the purpose of administering the SeniorSafety Scheme.


 * I, the proposer, confirm that I have informed the client that I have collected personal details and passed them to Help the Aged for the purpose of administering the SeniorSafety Scheme.

 
 
 

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Age UK is the new force combining Age Concern and Help the Aged. We will be known by our new name from Spring 2010.
The Age UK family includes Age Scotland, Age Cymru and Age NI.