Application for Donation of CARE Shop Goods

Application for Donation of Shop Goods
(This information will be treated in strict confidence)
Title*
Full Name*
Address*

Street Address

Street Address Line 2

Town/CityCounty

Post Code
Mobile Number
Please enter a valid phone number.
Email
example@example.com
How long have you lived in North East Lincolnshire
Your National Insurance No
Name of Partner
Partner’s Date of Birth

DayMonthYear
Date
Partner's National Insurance No
Do you or your partner receive income from paid work?

YesNo
Date you moved into or intend to move into your property

DayMonthYear
Date
How did you hear about CARE?
Please state type of state benefits you or your partner receive

Names and ages of all dependent children who live with you:

Rows	Name	Age
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6

Please use the section below to the list the items you require.

Necessary ItemsWhen applying for furniture and appliances, please list individual items. Please note, any items ofClothing, Homeware or Kitchenware do not need to be individually listed.

Rows	Necessary ItemsWhen applying for furniture and appliances, please list individual items. Please note, any items of Clothing, Homeware or Kitchenware do not need to be individually listed.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Have you received help from the CARE Shop in the last two years?

YesNo
If the CARE Shop has helped you in the last two years, please give details:
Please explain the reasons that have led to this need arising: (i.e: the story leading up to your present circumstances.)
PLEASE SIGN AND DATE THIS FORM AND RETURN IT: THE CARE SHOP, 46/47 ALEXANDRA ROAD, CLEETHORPES, DN35 8LE, OR EMAIL TO: shop@carenelincs.co.uk
Signature

Clear
Date

DayMonthYear
Date
Equal Opportunities Monitoring Form

We keep records of people who apply to us for support. This is to ensure that our service is provided on an equal basis without discrimination on the grounds of age, gender, race, ethnicity, sexuality, disability or religion. Any information you choose to give us will be treated in confidence and will be used for monitoring purposes only.

We keep records of people who apply to us for support. This is to ensure that our service is provided on an equal basis without discrimination on the grounds of age, gender, race, ethnicity, sexuality, disability or religion. Any information you choose to give us will be treated in confidence and will be used for monitoring purposes only.
GENDER

MaleFemaleNon/Binary/ Gender FluidOther
AGE

under1818-2425-2930-3435-3940-4950-5960-6970 +
RACE:

WhiteBlackAsianMixedOther
ETHNICITY:

BritishIrishAny other White backgroundAfricanCaribbeanAny other Black backgroundBangladeshiIndianPakistaniArabChineseAny other Asian backgroundWhite & AsianWhite & Black AfricanWhite & Black CaribbeanAny other Mixed backgroundGypsyRomaTravellerPrefer not to say
Sexual Orientation

BisexualGay/ LesbianHeterosexualPrefer not to say
DISABILITY: If yes, please tick the relevant box:

YesNoMobilityVisual ImpairmentHearing ImpairmentMental Health ConditionAutistic Spectrum ConditionLearning DisabilityProgressive Disability Chronic IllnessPrefer not to sayOther
RELIGION

BuddhistHinduSikhMuslimJewishChristianPrefer not to sayNot knownNoneOther
MARRITAL STATUS:

SingleMarriedSeparatedDivorcedLiving with PartnerOther
Thank you for taking the time to provide this information.
Marketing Permissions

Email
Date of Birth

MonthDayYear
Date

Necessary ItemsWhen applying for furniture and appliances, please list individual items. Please note, any items ofClothing, Homeware or Kitchenware do not need to be individually listed.

Rows	Not Satisfied	Somewhat Satisfied	Satisfied	Any thoughts?
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6

Should be Empty:

Application for Donation of Shop Goods

Please use the section below to the list the items you require.

PLEASE SIGN AND DATE THIS FORM AND RETURN IT: THE CARE SHOP, 46/47 ALEXANDRA ROAD, CLEETHORPES, DN35 8LE, OR EMAIL TO: shop@carenelincs.co.uk