ACTON (MIDDLESEX) CHARITIES – RELIEF IN NEED
Registered no. 211446
Applicant’s full name:
Mr/Mrs/Miss/Ms ...................................................................................................................................................................................
(Please print clearly)
Address: .................................................................................................................................................................................................
...................................................................................................................................................................................................
Postcode ................................................... Telephone number .......................................................................................
Age (if under 21) .................................. Nationality ....................................................................................................
Referred by ...........................................................................................................................................................................................
(Name, address, position, email address & phone number, please)
.................................................................................................................................................................................................
Date ......................................................
How long has the applicant lived in Acton? ................................. years
If recently moved to present address, please state previous address
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Full details of family:
What benefits, if any, does the applicant receive?
..................................................................................................................................................................................................
Has the applicant been visited? If so, by whom?
Has application been made to any other body? If so, which?
Please set out, in detail, on the reverse of this form, exactly what is being asked for and why; please give supplier’s name and exact cost.
Application to be returned to:
Clerk, Acton Charities, c/o St Mary’s Parish Office, 1 The Mount, Acton High Street, London W3 9NW