Application for an Allotment

Dobson Lane Allotments
Application Form

Title……… First name………………………...... …. Surname………………..…………………......

Address………………………………………………………………………..……………...…………………...... …

………………………………………………………………………...... …Postcode………………..………………

Daytime Telephone Number………………………………………………………………………..……………......

Alternative Daytime Telephone Number (eg mobile) ….………………………………………..……………......

Email address: ……………………………………………………………………………………..…….………......

Please note that residents of Whitnash and South Leamington will be prioritised.

Please indicate which size plot you are interested in. We will contact you when plots become available.

*A £2 concession is available is a person is in receipt of benefits/OAP

Large plot approx: 120 m2 Medium plot approx: 60 m2 Small plot approx: 30 m2

£30*£15*£10*

Do you own a car?Yes No

Do you intend to drive to the site?Yes No

Please state what your main purpose for an allotment is …………………………………………….………......

……………………………………………………………………………………………………………….………......

Have you ever rented an allotment before? Yes No

If so where and when was the plot surrendered? …………………………………………………….………......

Do you have an allotment at present?Yes No

How did you find out about the allotments at Dobson Lane? ………………………………………..………......

Please state if you are in receipt of benefits and interested in the concession

Your name and contact details will be kept by Action 21 to enable them to contact you in the future regarding any issues arising from the allotments. Please notify us of any change of address so we can contact you. If you would like us to remove your details from the mailing list then please phone Action 21 on 01926 339077.

If you are sent a tenancy agreement for an allotment plot and you do not respond within one calendar month your name will automatically be removed from the waiting list.

Please send this form to Natalie Surrage, DLCAA Site Officer:

Email:

Post: Apartment 4 Walnut Court, 35 Montgomery Road, Leamington Spa CV31 2TG

If you have any queries regarding applying for an allotment, please contact Natalie on the above email address or call 01926 450603.

Treating people fairly

Action 21 values and celebrates the diversity of all people living and working in Leamington Spa. By completing the nextpart of the form you are helping us to ensure everyone in our community is treated fairly. This information will be kept separately from your application and will not affect the way your application is dealt with, and you do not need to complete this form if you do not want to - we will deal with your application in any case.

All equalities information you give will be strictly confidential.

Sex: Female Male
Age: 18-24 25-34 35-44 45-54 55-64 65-74 Over 75

Asian or Asian British

Indian Pakistani Bangladeshi

Other Asian background………………......

Black or Black British

Caribbean African
Other Black background…………………......

Chinese 

Mixed

White & Black African White & Black Caribbean White & Asian

Other Mixed background ……………………………………......

White

British Irish

Other White background.………….……......

Other ethnic background

…………………......

Do you have any long-standing* illness, disability or infirmity? Yes No

* long-standing means anything that has troubled you over a period of time, or that is likely to affect you over a period of time

Does this illness or disability limit your activities in any way? Yes No
Does this illness or disability affect your:
Eyesight Hearing Mental Illness Mobility Other physical Other non-physical
Religion:
Buddhist Christian Hindu Jewish Muslim Sikh None Other………………......