Miscellaneous Application Form       Print

Please fill out all relevant fields.
Business Name:
Address:
Town / City:
Dublin Code: ( Where applicable )		Dublin 1 Dublin 2 Dublin 3 Dublin 4 Dublin 5 Dublin 6 Dublin 7 Dublin 8 Dublin 9 Dublin 10 Dublin 11 Dublin 12 Dublin 13 Dublin 14 Dublin 15 Dublin 16 Dublin 17 Dublin 18 Dublin 20 Dublin 22 Dublin 24
County:		Co. Antrim Co. Armagh Co. Carlow Co. Cavan Co. Clare Co. Cork Co. Derry Co. Donegal Co. Down Co. Dublin Co. Fermanagh Co. Galway Co. Kerry Co. Kildare Co. Kilkenny Co. Laois Co. Leitrim Co. Limerick Co. Longford Co. Louth Co. Mayo Co. Meath Co. Monaghan Co. Offaly Co. Roscommon Co. Sligo Co. Tipperary Co. Tyrone Co. Waterford Co. Westmeath Co. Wexford Co. Wicklow
Post Code: ( Where applicable )
Contact Name:
Telephone:
Fax:
Email:
Website Address:
Sub-Category:		Public Toilets
Suggest a Sub-Category:
Description: Please keep description about the accessibility of your premises to about 300 characters.		characters left
Example: Parking available adjacent to housewith 2 steps to main entrance 100 mm and 140 mm high. Spacious interior with four ground floor accessible bedrooms. Main bathroom and toilet are accessible. Grab rails fitted. Guide dogs permitted.
Accessible 1:			Wheelchair Accessible.
Accessible 2:			Wheelchair Accessible with an Assistant.
Accessible 3:			Accessible to someone with mobility difficulties, but able to walk up a minimum of three steps.
Guide Dogs:			Guide Dogs allowed.
Blind or Low Vision :			Access for Individuals Who are Blind or Have Low Vision.
Sign Language:			Sign Language Interpretation.
Large Print:			Accessible Print.
Braille:			Printed matter available in Braille.
Toilets:			Fully accessible disabled toilet.
Telephone:			Accessible Telephone.
Grab Rails:			Grab Rails Fitted.
Ramps:			Accessible Ramps.
Audio Visual:			Audio Visual aids available.
Reception / Service Desk:			Wheelchair accessible Reception / Service Desk.