Date: 19-05-2012

Please supply your personal details - all red boxes must be completed

Your Name		Please state any special delivery / collection requirements and any other relevant facts.
Business name
Address line 1
Address line 2
Town / City
County
Postcode
Email
Telephone number and/or Mobile number

Delivery / collection address if relevant

If different from address above please give details, otherwise leave blank

Contact name		Business name
Address line 1		Address line 2
Town / City		County
Postcode
Tel. number		Mobile number

ORDER FORM
Personnel		Hire per day	Number of persons	Number of days
Certificated Fire Marshall / Warden		£225.00
Security Attendant		£200.00
Date personnel hire period to start  - use format DD MM YYYY                        D    M    Y
Item		Rental per week	Quantity required	How many weeks
Fire Extinguisher - any type - to be agreed upon confirmation of order		£10.00
Fire Blanket		£5.00
First Aid Kit 1-10 man		£6.00
First Aid Kit 1- 50 man		£12.50
Fire Extinguisher Stand - single		£8.00
Fire Extinguisher Stand - double		£8.00
Extinguisher Trolley - single		£15.00
Extinguisher Trolley - double		£15.00
Extinguisher Trolley - triple		£15.00
Safety Sign - any type - to be agreed upon confirmation of order		£5.00
Megaphone		£20.00
Arm Band - any type - to be agreed upon confirmation of order		£5.00
Fire Extinguisher Cabinet - single		£12.00
Fire Extinguisher Cabinet - double		£12.00
Fire Bucket		£5.00
Howler Alarm		£25.00
Rotary Alarm Bell		£6.00
Escape Ladder		£10.00
Date equipment hire period to start     - use format DD MM YYYY                     D    M     Y
Delivery / Collection		Fee	Please tick options required
We deliver items to you	Up to 40 miles	£35.00
	Over 40 miles	£50.00
We collect items from you	Up to 40 miles	£35.00
	Over 40 miles	£50.00
You collect & deliver back to our office at your own expense		No delivery charge
All prices exclusive of VAT
Security check Please type the "fourth" one of these characters in the box below   One character only please