VAT Exemption Certificate
Email address *
Full name of eligible person
Karin Jayne Annette Kelly
Your answer
9 Conference Close
Your answer
Chingford
Your answer
LondonCounty
Your answer
E4 6TY
Your answer
By completing this form you are declaring that you are an eligible person under paragraph 1 of VAT Leaflet 701/7/86 and that you are a person with a disability, illness or disease that requires the use of the EMS Physio Medical Device that you wish to purchase
Please enter a description of your disease, illness or disability below.
The clinically diagnosed name will suffice - further detail is not required e.g. Osteoarthritis
Your answer
You will be receiving goods from EMS Physio Ltd, Grove Technology Park, Downsview Road, Wantage, Oxfordshire, OX12 9FE. Please complete the details of the goods which you require for your personal or domestic use.
Your answer
By completing this form you are claiming that the supply of these goods or services is eligible for relief from value added tax under Group 14 of the Zero Rate Schedule to the Value Added Tax Act 1983
Please enter your name below to confirm this statement
Your answer
Please select todays date
MM
/
DD
/
YYYY
There are penalties for making a false declaration. If you are in any doubt about your own eligibility or the goods or services you are buying, you should get advice from any local VAT office before completing this declaration.
Data Protection Statement

As a financial statement this document will be retained securely along with your financial transaction records with us for 7 years after which time it is securely shredded on site. Data processors for your purchase of a medical device from EMS PHSYIO LTD will view this form for confirmation of eligibility but it is not copied or shared nor the content recorded in any other location. We do not share the information, that you share with us, with any third parties.

For further information about Privacy and your rights visit our website EMSPHYSIO.CO.UK

EMS PHYSIO LTD is a Private limited Company. Registered office address EMS PHYSIO LTD, Grove Technology Park, Downsview Road, Wantage, Oxfordshire, OX12 9FE Registration number 601612

Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google.