PRIDE - Alarms For The Elderly

APPLICATIONS

To apply for a PRIDE alarm, simply fill out this form and click the "Apply now" button below. An e-mail will then be sent to you stating if you are eligible.
* Indicates required field

*First Name:

*Last Name:

*Age:

*Ethnicity:

* E-mail Address:

*House number/street name

*Town:

*County:

*Postcode:

Have you or the person you are applying for been a victim of a crime?
Yes No

Approximate date of offence:

Installation address if different from above

Address: (house number/name)

Town:

County:

Postcode:

How did you hear about PRIDE?
If other, please specify:

Additional information:

I understand that the installation cost is included in the unit price, and is subject to the provision by the recipient of a 3 pin mains socket.

Price and specification may be subject to change without prior notice.

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