Carer Card Scheme Provider Application Form

Please complete the details on the below form. If you need assistance completing any part of this form, please contact Lanarkshire Carers Short Breaks Bureau on 01698 428090.

Business Name*

Please provide a brief description of what your business does*

Business Address*

Street Address

Street Address Line 2

Town / City

Postcode

Website*

Main Contact Name*

First NameSurname

Job Title / Position*

Main Contact Phone Number*

Please enter a valid phone number.

Main Contact Email Address*

example@example.com

In the event that we cannot get in touch with the main contact detailed above, please provide details or a secondary contact (if applicable) below:

Secondary Contact Name

First NameSurname

Job Title / Position

Secondary Contact Phone Number

Please enter a valid phone number.

Secondary Contact Email Address

example@example.com

Please provide details of the specific offer or discount you are willing to provide below, including any conditions or exclusions. We will use this information for promotional purposes:

Details of offer/discount you will provide*

Conditions or exclusions*

Start Date of Carer Card Offer*

Date

Please provide us with your company logo and any other relevant imaging or publicity material that we can use to promote you as a provider of the Carer Card Scheme.

IMPORTANT

You must own the copyright for any logos, branding, imaging or promotional material you provide us for use in publicity material. If we decide to use this, you must give us your explicit consent to do so.

If we suspect that any logos, branding or imaging you have provided to us infringes copyright law, we reserve the right not to use it in publicity material.

The following file formats are supported for uploading attachments: .pdf, doc, docx, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif

Individual file upload limit: 2MB

File Upload*

Upload a File

Please do not upload a stock image unless you have a license that you can provide. Please ensure the image is a high-quality image.

Use the space below to detail any specific requirements regarding the use of your logo, branding, imaging or publicity material. You may also use this space to include links to any relevant web content you wish to provide:

Additional Details

By clicking on the link below, you acknowledge that you have read our Terms and Conditions and that you consent to Lanarkshire Carers Centre Ltd using any logos, branding or imaging you have provided:

Acknowledgement*

I agreeI do not agree