Hippo bag request form

Please fill in this form with all your up to date details and click submit.

Note: The Hippo Bag may not be suitable for toilet cisterns that have less than 6.5ltr capacity or are dual flush.

(Please note that fields marked * are mandatory)

Title*

First name*

Surname*

Property address*

Postcode*

Telephone number (inc. STD code)

Alternative telephone number

Are you a council tenant

Yes

Email address*

Customer details *

Domestic

Non Domestic

Unmeasured

Measured

Number Required
(Max 3 per customer)

Any additional water saving devices at property? (tick box)
Number of dual cistern(s)
Number of water butt(s)
Other

How did you hear about Hippo Bags?
DCWW Publication	If so which one?
Internet Website	If so which one?
Event	If so which one?
Environmental Agency
Other

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