LEASEHOLDERS CONTACT INFORMATION

Please return to: Vikki Brown, Bournemouth Borough Council, Housing, Parks and Bereavement Services, The Kinson Hub, Wimborne Road, Kinson, Bournemouth BH11 9AW

Leasehold Property Address
Leaseholders name(s)
Address for correspondence
(if different from the leasehold property address above)
Home Telephone Number / Work Telephone Number
Mobile Telephone Number / Number to use in an Emergency
Email address
Do you sub-let your property? / Yes / No(please delete as applicable)
Name and contact telephone number of managing agents (if applicable)
If you let your home and do not use a Managing Agent please provide your tenants name and telephone number

Do you have any preferred communication requirements?(please circle those preferred)

Interpreter / Large Print / Telephone Call / Visit / Standard Text
Audio / Braille / E-Mail / No preference
Other (please specify)

Continued over…

Gas Servicing

The Council’s Building Maintenance Team may be able to offer gas servicing for your boiler, central heating and appliances in the future at a reasonable cost.

Does your leasehold property have a gas supply? / Yes / No (please delete as applicable)
Would you be interested in having your gas service carried out by the Council? / Yes / No (please delete as applicable)

We are trying to identify likely demand and indicating ‘Yes’ now does not commit you to this service. Further consultation with leaseholders will be carried out.

Diversity Information

It is important that we know who our residents are, and what differences there are, to make sure our services are fair and provided with everyone’s needs and cultures included. We would like you to complete the questions below. You do not have to answer either of the questions but doing so will assist us in delivering our service to you.

Ethnicity

Please tell us your ethnic group by ticking the relevant box below. If there are two adults at your address include both. If you are both in the same group tick the box twice.

Indian / White & Asian
Pakistani / Any other mixed background
Bangladeshi / Chinese
Any other Asian background / Any other ethnic Background
Black British
Black Caribbean / British
Black African / Irish
Any other Black background / Any other white background
White & Black Caribbean
White & Black African / Prefer not to say

Disability

If you are resident at the leasehold property and have any disabilities please tell us what they are. The Disability Discrimination Act 1995 defines a disability as a “physical or mental impairment which has a substantial and long term adverse effect on your ability to carry out normal day-to-day activities.” (Please circleall boxes that apply)

Leaseholder 1 name:
Mobility / Sight / Hearing / Communication
Other (please state) / Prefer not to say
Leaseholder 2 name:
Mobility / Sight / Hearing / Communication
Other (please state) / Prefer not to say

Finally please sign this form and return it to me.

Signature of leaseholder(s) / Date