Company Name (If Applicable)
Your Name (If Applicable)
Your Email
Contact Phone Number
Address for the Service at Collection
Address for the Service at Delivery
Expected Date of Contact with Chess
Uplift / Collection Date
Delivery Date
Services if Other
Is anyone who lives at the service address currently under any form of self-isolation as the result of an order of any government authority or as the result of a recommendation of a health professional? YesNo
In the last 14 days, have you or anyone at the service address been in physical contact with anyone who has been diagnosed with the COVID-19 virus? YesNo
In the last 14 days, have you or anyone at the service address has been in physical contact with anyone who is in self-isolation due to the COVID-19 virus? YesNo
In the last 14 days, have you or anyone at the service address has been in physical contact with anyone who has recently visited any overseas country? YesNo
In the last 14 days, have you or anyone at the service address has been in physical contact with anyone who has recently visited or returned from Interstate? YesNo
In the last 14 days, has anyone at the service address experienced flu-like symptoms (sore throat, fever, tiredness, and cough) following overseas travel and/or physical contact with someone who has recently returned from overseas? YesNo
Consent and Accuracy I confirm that I have read the Privacy Collection Notice and that I consent to provide the information above, which I certify is accurate to the best of my knowledge.
