Membership Referral Form - Poole Waste Not Want Not

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Part 1 – Primary Client’s Details (to be completed by Referrer)

Your Name(Required)

First Last

Your Address

Street Address Address Line 2 City ZIP / Postal Code Country

No of Adults

(Please write in words)

No of children/siblings in our household (Under 16):

(Please write in words)

No of children/siblings in our household (16+):

(Please write in words)

How did you hear about us?

Preferred Method of Contact

Your Email Address

Email Address Confirm Email Address

Your Phone(Required)

Employed:

Yes

In Receipt of Benefits

Yes

Age Group

16-24

25-39

40-64

Over 65

Ethnic Origin

White

Black

Asian

Other

Optional (in accordance with the Commission for Racial Equality)

Poole Waste Not Want Not (PWNWN)

Poole Waste Not Want Not (PWNWN) provides fresh, healthy food to members of the community who through no fault of their own have ‘insufficient disposable income’.

Part 2: Referral Reason

Please provide evidence

Reason

Insufficient Disposable Income

Employed

Universal Credit

Other

Part 3: Organisation’s Details

To be completed by Poole waste Not Want Not

Organisation Name

Issuer's Name

Contact Telephone Number

Organisation Address

Agreement - Full Name

Type your full name here as approval and signatory for the agreement.

Issue Date

People struggling to pay bills due to lack of funds, universal credit claimants or in receipt of a means -tested benefit (e.g., low pension- loss of earnings – long term sick, Universal credit. Income-based jobseekers’ allowance. Income-related employment and support allowance. Income support. Working tax) Families of households on minimum wage may be eligible to become a member please come in or call for more information. Individuals need to bring proof via letter or Journals. A membership is valid for 6-months however if your situation changes at any time please inform a member of the team. 70 High Street, Poole, Dorset, BH15 1DA, Tel: 01202 402818. Registered Charity No 1166798

70 High Street, Poole, Dorset, BH15 1DA, Tel: 01202 402818. Registered Charity No 1166798

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Member Referral Form

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Part 1 – Primary Client’s Details (to be completed by Referrer)

Poole Waste Not Want Not (PWNWN)

Part 2: Referral Reason

Part 3: Organisation’s Details

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