Please complete the details below to ensure we provide you with the right service. If you are a homeowner or private landlord we shall need your credit/debit card number. Please be sure to provide a daytime contact number to allow us to take card details from you and confirm the inspection.

Please note: All fields marked with a * are required to process your enquiry.

Are you a: * Letting Agent Landlord Homeowner
Please specify inspection required: * (see Products and Services)
G1 LPP PE1 E1 GB1 PSPP S1 E2 GE1 HSR BS FWSR
Inspection due date: * 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2008 2009 2010
Please allow 10 working days before your inspection due date. If your inspection is urgently required please call 0800 587 9999
Please Tick Items to be Tested (if known): Gas Appliances Boiler Cooker Oven Hob Fire Water Heater Electrical Appliances Washing Machine Fridge Freezer Fridge/Freezer Microwave Cooker Hob Fire Dishwasher Spin Dryer Lawn Mower Iron Toaster Kettle Vacuum/Hoover Table Lamps Other (Please Specify) Landlord / Homeowner / Company Details: Title: * -select- Mr Mrs Miss Ms Dr Prof Lady Sir Lord Rt Hon Full Name: * Company: (if applicable) Telephone: * Fax: Email: * Home Address: * Postcode: * Home Safety Kit required (£60 inc VAT): * No Yes Details of property to be inspected: Address: * Postcode: * Access Arrangements: * Via Keys Address of key holder: Via Tenant: Contact Details: Other access arrangements

Reg. Nr 171224

GAS-ELEC SAFETY SYSTEMS
Brooklyn House, Money Lane, The Green, West Drayton UK UB7 7PQ
Tel: 01895 420777 | Fax: 01895 420776 | E-mail: sales@gas-elec.co.uk