*Name of business

*Address(es) of business

*Which areas do you cover?

*Telephone number (for customers)

*Email address (for customers)

*Website

*A brief description of your business (we will use this text in the directory)

*Details of any offers and any restrictions (we will use this text in the directory)

*How can carers access the offer, e.g. do they need to mention the card before the purchase is made? (we will use this text in the directory)

*Contact name

*Job title

*Telephone number (for our use only)

*Email address (for our use only)

*Would you like one of the following 'Carers Accepted' stickers? *Would you like one of the following 'Carers Accepted' stickers? Window sticker Surface sticker (for a vehicle or till)

Additional questions of comments