Claimants full name :                                        

Address :                   

Postcode :                 

Tel No :                      

Email Address :       

I declare that the person named above is chronically sick or has a disabling condition by reason of : (Please give full and specific description of your condition)

I declare that the person above is receiving goods which are being supplied to me/them for domestic or personal use from Choice Mobility Ltd  (Description of goods)

By submitting this form, I declare that I am claiming relief from value added tax (VAT), and that I am aware that there are penalties for making false declarations.   This is my electronic signature.