Assisted Collection Request Form

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Application For The Assisted Collection Service

By completing the form below you are requesting assisted collection for your household waste. The Council will consider each application on its merits and will only provide an assisted collection service if you cannot genuinely move your refuse bin, purple refuse bags or recycling boxes and bags.

As part of the application process a home visit will be carried out by a waste monitoring officer upon receipt of your application form. Please include a contact number on the form so that an appointment can be booked with you.

If you qualify for assisted collections you will be notified within 10 working days.

*Please note, if you are applying for additional capacity due to medical reasons you will need to provide a letter and signature from your District Nurse, Health Visitor or Care Worker to validate your request. If you are unable to do this, please provide evidence to support your disability e.g. copies of your DLA or Attendance Allowance, etc. to validate your claim.

Declaration

By submitting the form below you are declaring that the information in the form is a true representation of your current circumstances. You must understand that giving false information will result in the cancellation of your assisted service. If your circumstances change you must inform the Waste Management Team immediately on 01773 841326.

Assisted Collection

PERSONAL DETAILS

Title

First Name(s)

Surname

Contact Number

Email Address

Address

If the property is in the Amber Valley area please enter the postcode or the first few letters of the street. Otherwise enter the full address in the box below.

REASON FOR APPLYING FOR AN ASSISTED COLLECTION

1. I have a temporary physical disability / illness that has been diagnosed by my Doctor that prevents me from moving my wheelie bin, refuse sacks, recycling bin and bags.

Yes
No

If yes, how many months do you anticipate that you will need the assisted collection for

2. I have a permanent physical disability / illness that has been diagnosed by my Doctor that prevents me from moving my wheelie bin, refuse sacks, recycling boxes and bags.

Yes
No

3. There is no other resident at the property that can move the refuse / recycling receptacles for me.

Yes
No

SUPPORTING INFORMATION

Please tell us why you feel you require assisted collection. Please include details about your medical condition and any other information to support your application.

DECLARATION

Please confirm if you agree to the declaration listed above:

Yes
No

Applicants may submit their form now

FOR OFFICE USE ONLY

Visiting Officer:

Visiting Officer Signature:

Date of Visit:

Does the customer qualify? Yes / No

Customer - Print Name:

Customer - Sign:

Contact Details

Tel: 01773 841326
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Do you need further information?

If for some reason you are unable to find the information which you require on our website, you can contact us by post, email or by phone. Our Key Managers Contact List can be viewed here

Town Hall, Ripley, Derbyshire, DE5 3BT
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01773 841326
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refuse@ambervalley.gov.uk