Period Dignity Order Form

By submitting this request I confirm that I am unable to obtain free disposable period products offered by my local authority reasonably easily, and that no one else is able to do so on my behalf. We can only accept orders within the ML6 postcode area.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

***Personnal details are solely for delivery purposes and will not be held or passed on to any third parties.

***Please note we require a completed form for each individual at a household.

DELIVERY DETAILS

Delivery will be made within 7-14 days of receiving the completed form, usually between the hours of 10-2pm.

If no one is home the delivery will be left in a safe place, if you have a preference please tell us below. (If no one is home and there is no safe place to leave the package we cannot guarantee re-delvery)

If there is no reply when attempting delivery please leave my package...

Please tell us of any access issues (security entrance, stairs/lifts etc, are there any dogs in home or any other potential issues)

PLEASE SELECT THE PRODUCTS YOU REQUIRE FROM THE LIST BELOW

Press on towel - ultra long - with wings (Bodyform)Press on towel - regular - with wings (Bodyform)Press on towel - regular - without wings (Bodyform)Press on towel - long - without wings (Always)Tampons - regular - with applicator (Tampax)Tampons - super - with applicator (Tampax)Tampons - regular - without applicator (Lil-lets)Tampons - super - without applicator (Lil-lets)Breathable Pantyliner (Johnson & Johnson)

Period Cup - Small - Suitable for 25 years and under, or not given birth - 7cm in length with 4cm diameterPeriod Cup - Large - Suitable for 25 years and over, or not given birth - 7.5cm in length with 4.5cm diameterPeriod Pants - XS - no need for additional period products - wear for up to 10-12 hoursPeriod Pants - Small - no need for additional period products - wear for up to 10-12 hoursPeriod Pants - Medium - no need for additional period products - wear for up to 10-12 hoursPeriod Pants - Large - no need for additional period products - wear for up to 10-12 hoursPeriod Pants - XL - no need for additional period products - wear for up to 10-12 hoursMy First Period Kit

We will supply approx. 2-3 months of single use products and one weeks supply of reusable products when available. Deliveries will be made within 7-14 days.

Diamonds in the Community (SC049275) - www.diamondsitc.com - diamondsitc@hotmail.com