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Applicant Details (Complete if you are applying on someone’s behalf)I am the recipient and completing this form for myselfIf you are applying for someone else:

Recipient Details

Full Name *

Date of Birth

Phone Number

Email Address *

Home Address

Number

Eircode

County

Your Full Name *

Relationship to Recipient

Your Contact Phone Number

Your Email Address *

Eligibility CategoryPlease select one of the following:The recipient is aged 65+ and has been discharged from a hospital or care facility after a stay of at least 3 monthsThe recipient is currently undergoing or recovering from cancer treatment

Brief Description of Circumstances

Home & Cleaning Details

Type of Property:

Number of Bedrooms & Bathrooms

Level of Dirtiness – Drop down (slightly dirty, medium dirty, very dirty)

Any Hazards or Special Access Notes?

Are there pets in the home?Yes (please specify)No

Describ Shortly

Preferred Cleaning Type:Standard CleaningDeep Cleaning

Preferred Time:MorningAfternoon

Mandatory Supporting Documentation

Please upload the following documents to support the application:

A hospital/nursing home discharge letter confirming admission and discharge after a
stay of at least 3 months
OR
A medical letter clearly confirming a cancer diagnosis and treatment/recovery status

Accepted file formats: PDF, JPG, PNG | Max size: 5MB

No file chosen

Consent, Terms & GDPR *I confirm the information provided is accurate and completeI confirm the recipient resides at the address providedI understand this is a once-off complimentary service subject to availabilityI agree to be contacted by Busy Bee Cleaning in relation to this applicationI agree with the Terms and Conditions (this needs to be hyperlink, can be an active back page)I have read and understood the GDPR Data Protection Notice (this needs to be hyperlink, can be a back page)

GDPR Notice:

Terms and Conditions | GDPR Data Protection Notice

Your personal data will be processed securely and used only for the purposes of
this application, service delivery, and internal reporting. Data will never be shared with third
parties without consent. For queries, contact: team@busybeecleaning.ie