Lifeline initial application form

Where do you reside? *

Merthyr Resident

Non Merthyr Resident

As a Merthyr resident, you will need to pay an initial fee of £220. Once you have completed and submitted the application form you will be redirected to our payment system.

As a Non Merthyr resident, you will need to pay an initial fee of £240. Once you have completed and submitted the application form you will be redirected to our payment system.

First Name *

Last Name *

Date of Birth *

Address *

Postcode *

Key Safe Number (if applicable)

Home Telephone Number

Mobile Phone Number

Email Address *

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Lifeline initial application form