BCP Appliance Scheme Form

• Customer Name:

• Address
  Address

• Prepared by

  Steve Bright

  Johnny Fox

  Chris Denman

  Gavin Byrne

• Conducted on

  Date

Please select which appliances the customer needs. They can have up to 2 appliances plus a microwave if replacing existing appliances or up to 3 and a microwave if setting up a home and with no existing appliances.

• Family Size Fridge Freezer (55cm W x 183/174/166cm H x 54/58cm D)

• Specify H/W

• Fridge With/Without Icebox (54/55cm W x 84/85cm H x 59/60/62cm D)

• Specify Size

• Under Counter Freezers (54/55cm W x 84/85cm H x 60/62cm D)

• Specify Size

• Electric Cooker (50/60cm W x 90cm H x 60cm D)

• Specify W

• Gas Cooker (60cm W x 90cm H x 60cm D)

• 7KG Washing Machine (60cm W x 85cm H x 52/54/60cm D)

• Specify D

• 8KG Washing Machine (60cm W x 85cm H x 52/54/60cm D)

• Specify D

• Black Microwave (44/54cm W x 25/30cm H x 35/40cm D)

• Specify Size

• Does the resident have any communication issues?

  Yes

  No

  N/A

• Please Specify

• Does anyone else need to be contacted to make arrangements?

  Yes

  No

  N/A

• Please Specify

• If parking permit is required, is the resident able to make one available for the crew?

  Yes

  No

  N/A

• If the property a Flat/Maisonette?

  Yes

  No

  N/A

• Which floor is the property on?

• Is there a Lift in the building?

  Yes

  No

  N/A

• Please check how close drawers and other items are to appliances and are you satisfied that there will be adequate clearance when opening any doors, and that drawer doors will not be impeded by new appliances.

  Yes, I am Satisfied

  No, Not Satisfied

• Please note why not Satisfied and add photo evidence.

• Is there a socket near the appliance (if cooker, an Isolation switch & hardwired plug socket?)

  Yes

  No

  N/A

• If ordering a washing machine, will the crew have access to turn the water on/off, and do the pipes have access to the plumbing under the sink?

  Yes

  No

  N/A

• For Cookers, The Hot Zone is the area behind & above the hob (65cm above for Electric cookers, and 5cm each side) Can you confirm there is no wallpaper or any combustible material in the hot zone?

  Compliant

  Non-Compliant

  N/A

• Please add any other information about accessibility of the property

• The resident confirms that they are responsible for/own the appliance(s) being replaced/installed

  Yes

  No

  N/A

• Who owns the appliance?

• Is there an existing appliance to be removed? (under BCP we can supply first time appliances)

  Yes

  No

  N/A

• The resident understands that the existing appliance(s) (at least 8 years old) will be removed & disposed of when the new appliance(s) are being delivered

  Yes

  No

  N/A

• Reason Why?

• Does the resident have any Health Needs? (e.g., needs fridge to store medication or carers need washing machine to wash clothes/bedding)?

  Yes

  No

  N/A

• Please Specify

• Any other disabilities, frailties etc, in the property, including whether customer has a carer?

  Yes

  No

  N/A

• Please Specify

• Best times and days to contact resident to arrange delivery?

• Any other helpful notes

• By signing below, I agree that it has been explained to me in fall the process for receiving my new appliance(s) and that the delivery company will contact me directly to arrange a convenient time to deliver. Also that i am the owner of the appliance(s) and these will be removed in receipt of delivery.

  Sign

• Assessor Signature

  Sign