Riser Recliner Assessment Appointment

							Manual Wheel Chair Hire for Royal Cornwall Show 2012                             For office use only
                                                                                 Date of application:____________

       Please insert, circle or delete as appropriate

 User’s name:                                                    Dates and times required:

                                                                 Thursday 7th Friday 8th Saturday 9th
 User’s telephone number:                                          June               June          June
                                                                   am/pm              am/pm         am/pm
 Driver’s number for contact at the show:


 User’s address:                                                 Person making application:


                                                                 Contact number if to be contacted in
                                                                 preference to the user:




                User information and preferences (insert, circle or delete as appropriate)

 Height:                             Any other concerns/conditions to be aware of :

 Weight:


                                                    Rubrick

The morning booking fee covers from 0830 to 1300 whereas the afternoon fee covers from 1330 to
1700. Returning the chair late, beyond these times will incur an additional fee.

VAT relief Declaration: I am chronically sick or have a disability (as detailed below) and I am eligible
for relief from VAT under the VAT act 1994. Note: It is a criminal offence to make a false declaration.

Condition: ____________________________ Signature: ___________________ Date: ___________


                   Number         At         Cost
   Whole days                £15.00                       For office use only:
                             (£18.00 inc
                             VAT) each                    Payment received       yes / no   Date:
   Half days                 £7.50
                             (£9.00 inc                   Payment by credit card:
                             VAT) each
                                                          Till receipt number:
                             Total


I have read the details above and the conditions of hire overleaf and accept them. Enclosed is the payment for
the above detailed hire dates.

Signed: ________________________________________                  Date: _______________________