REAL NAPPY APPLICATION FORM Please Note - To apply for a Real Nappies for Lancashire Voucher You should be a resident within Lancashire, Blackpool or Blackburn with Darwen (if you're unsure please check the list of districts on the web-site). You should have a child under the age of 18 months old, or expecting a baby before 31st March 2011. We will acknowledge receipt of your application and send out the voucher 6 weeks before your due date or within 10 days if your baby is already born. Title Dr Miss Mr Mrs Ms Forenames Surname House Number or House Name Street Town County Post Code   District Please select... Blackburn Blackpool Burnley Chorley Fylde Hyndburn Lancaster Pendle Preston Ribble Valley Rossendale South Ribble West Lancashire Wyre Telephone Email Address Baby's date of birth (actual or due)* * To qualify for the 2010/11 scheme your baby must be under 18 months old or your due date must be before 31st March 2011. Number of Other Children 0 1 2 3 4 5 6 7 8 9 10 If you have more than one child under 18 months old by 31st March 2011 then please enter the dates of birth for these children as well. Have you had a nappy voucher from Lancashire County Council or Global Renewables in the past?** YesNo ** Vouchers are limited and are not available to parents who have received a Bottom Line Incentive Voucher in the past. Do you currently use real nappies? YesNo Do you currently use a real nappy laundry service? YesNo Where did you hear about the Bottom Line Nappy Project? FriendDistrict Council Health ProfessionalNappy/Laundry Agent NewspaperBirth Certificate TalkOther EventChilds Talk Magazine Other; Please specify Please select how we may contact you in future Email Telephone Post Please type the characters above