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employment questionnaire

Please complete and submit the questionnaire below and a draft of the LPA will be prepared and emailed to you.

If you require a Property and Affairs LPA please ignore the last question concerning consent to life-sustaining treatment.

If you require a Personal Welfare LPA please ensure you answer the the consent to life-sustaining treatment question.

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Donor details
 
Full name  
  5  
Address  
   
Email address  

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Telephone  
   
Mobile  
   
Date of birth  
   
Otherwise/previously known as  
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Attorney details
 
Attorney 1 – Full name  
     
Attorney 1 – Date of Birth
 
   
Attorney 1 – Telephone  
   
Attorney 1 – Mobile
 
   
Attorney 1 – Email  
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Attorney 2 – Full name  
     
Attorney 2 – Date of Birth
 
   
Attorney 2 – Telephone  
   
Attorney 2 – Mobile
 
   
Attorney 2 – Email  
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Additional information
 
Provide a brief description of any restrictions/conditions/guidance to be added to the LPA  
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Notifying others of LPA
 
    Please note that if you do not notify family/friends that you are entering into an LPA then two Certificators will be needed.
   
Contact 1 – Full name  
   
Contact 1 – Telephone  
   
Contact 1 – Email  
  5  
Contact 1 – Address  
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Contact 2 – Full name  
   
Contact 2 – Telephone  
   
Contact 2 – Email  
  5  
Contact 2 – Address  
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Contact 3 – Full name  
   
Contact 3 – Telephone  
   
Contact 3 – Email  
  5  
Contact 3 – Address  
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Contact 4 – Full name  
   
Contact 4 – Telephone  
   
Contact 4 – Email  
  5  
Contact 4 - Address  
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Contact 5 – Full name  
   
Contact 5 – Telephone  
   
Contact 5 – Email  
  5  
Contact 5 – Address  
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Cerificator    
   
Name  
   
Telephone  
   
Email  
   
Address  
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Alternatively LZW can act  
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If you require a Personal Welfare LPA please select one option   Attorney will have authority to give or refuse consent to life-sustaining treatment
Attorney will not have authority to give or refuse consent to life-sustaining treatment
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Landau Zeffertt Weir Solicitors
10 Bickels Yard, 151-153 Bermondsey Street, London Bridge, London SE1 3HA
T: 020 7357 9494 F: 020 7357 9696 E: info@lzwlaw.co.uk