Surrey and Borders Partnership Co-production form - Surrey Coalition of Disabled People

Surrey and Borders Partnership Co-production Payment Form

Your Contact Details

Name(Required)

Date of birth(Required)

Address(Required)

Street Address Town County Postcode

Email(Required)

Phone(Required)

How would you prefer us to contact you? (Email, phone or post)

Preferred time of day to be contacted by phone, if any:

Are you a member of FoCUS

Yes

If no, would you like to be contacted about becoming a member?

Yes

Co-production Activity

Name of Activity(Required)

Number of hours completed. Paid at £15 per hour(Required)

How would you like to receive the payment?

Vouchers – please specify which company you would like the vouchers for

Payment into bank account – please provide bank details

Account Name

Bank

Account Number

Bank Sort Code

Please note, we aim to get your payment to you within 2 weeks of the event. Payments are made on the second and last Friday/Saturday of the month.

Consent

I consent to Surrey Coalition of Disabled People storing and processing my personal information in order to manage and communicate with me regarding my application.

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