Maintenance Request

1

Full Name* This field is required.

First Name

Last Name

2

Full Address* This field is required.

3

E-mail* This field is required.

4

Best Phone Number* This field is required.

Area Code

Phone Number

5

Please enter details of requested work and/or description of problem * This field is required.

6

Picture (if any)

Drag and drop files here

Select files to upload

Max. file size: 1.0MB

7

Does anyone in your household have any symptoms of coronavirus?The symptoms being a new continuous cough and/or high temperature. Click here for more information* This field is required.

Yes

No

8

Is anyone in your household being tested for coronavirus?* This field is required.

Yes

No

9

Is anyone in your household self-isolating due to potential coronavirus infection?* This field is required.

Yes

No

10

Has anyone in your household been in contact with someone who has tested positive for coronavirus?* This field is required.

Yes

No

11

Is there a vulnerable occupier at this property?* This field is required.Although there is no legal definition of vulnerable occupier, an occupier is generally considered to be vulnerable if they have a characteristic that means that the issue being raised would have a materially greater negative impact on them than on someone who does not have that characteristic. Examples of such characteristics include: Mental health needs Learning difficulties Aged over 65 years Aged under 16 years Severe physical health problems, debilitating illness or disability The recently bereaved Pregnant women

Yes

No

12

Signature - I confirm the information is true. -

Clear

13

Please verify that you are human* This field is required.

14