Name* address* Telephone Mobile* Email* Postcode* Address covered by Home Services Care Plan: (if different from above) Care Plan Gas Heating Care Plan Option 1 (Service Only) Option 2 (Boiler and Heating System) Make Model GC Number Location System Type Age Plumbing Care Plan Electrical Care Plan Gas Fire Care Plan Make Model GC Number Location Age Intial Annual Price: Instalments: Annual Payment £ Monthly£ Preferred Payment Date 15th Preferred Payment Date 28th Minimum contract period: 12 Months Has anybody recommended us to you?YesNo The Care Plans are provided by Care Plans Services Tamworth Limited, Unit 1, Sterling Park, Claymore, Wilnecote, Tamworth Staffordshire B77 5DQ and are subject to terms and conditions. A copy of our terms and conditions are available here. If you would preffer to be contacted by GST for you bank details please tick here Your account details Bank Name: Address: Branch: PostCode: Bank/Building Society account number: Branch sort code: Name (as appears on account): Instructions to pay your Bank or Building Society Please pay Care Plan Services Tamworth Ltd Direct Debits from the account detailed in this instruction subject to the safe guards by the Direct Debit Guarantee, I understand thet the instructions may remain with Care Plan Services Tamworth Ltd, if so, details will be passed electronically to my Bank/Building Society Banks and Building Societies may not accept Direct Debit instructions from some types of account. Customer Signature