Curtain Referral Form
Name
Phone
Address
Email
You will need to apply through one of the following categories for the application to be lodged - please select which:
Referral via Agency
Community Services Card
Gold Card
Student ID Card
Referral Agency
Contact Person
Community Services Card number
Expiry Date
Gold Card number
Student ID number
Expiry Date
How did you hear about us?
Statistical Information Required
House
Own Home
Rented
DCC
Kainga Ora
Other (please specify in box below)
Ethnicity
NZ European/Pākehā
NZ Māori
Iwi (please specify in box below)
Pacific Island
Asian
Other (please specify in box below)
Health: Please state what medical conditions people have in your home and the number of people in your home that have medical conditions.
Total number of people in your home aged 0–4 years
0
1
2
3
4
5
6+
Total number of people in your home aged 5–14 years
0
1
2
3
4
5
6+
Total number of people in your home aged 15–19 years
0
1
2
3
4
5
6+
Total number of people in your home aged 20–29 years
0
1
2
3
4
5
6+
Total number of people in your home aged 30–64 years
0
1
2
3
4
5
6+
Total number of people in your home aged 65+ years
0
1
2
3
4
5
6+
Total number of people in your home
Curtain Measurements
Measure your windows exactly as detailed below. Please note that we do not supply curtains for; spare bedrooms, offices, studies, bathrooms, kitchens and we do not have net curtains. Kitchen curtains are only provided if part of the living area, e.g. open plan.
How to measure your windows
– Please use centimetres:
Track Width:
Measure your track, If there is no track, measure outside edges of the frame.
Window Length:
Measure from the top of the track to the bottom of the windowsill.
Drop Length:
Measure from the top of the track to the floor.
Detachable linings:
Please meassure Curtains rather than track.
Name of Room | window
Track Width
Window Length
Drop Length
Name of Room | window
Track Width
Window Length
Drop Length
Name of Room | window
Track Width
Window Length
Drop Length
Name of Room | window
Track Width
Window Length
Drop Length
Name of Room | window
Track Width
Window Length
Drop Length
Let us know if you have any colour preferences, or if you have any further information we'll need:
Linings
(use this section if applying for linings only)
Room name
Curtain Width
Curtain Drop / Length
Room name
Curtain Width
Curtain Drop / Length
Room name
Curtain Width
Curtain Drop / Length
Room name
Curtain Width
Curtain Drop / Length
Room name
Curtain Width
Curtain Drop / Length
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