I ……………………………………………………………………………………………………………(persons full name)

…………………………………………………………………………………………………………………………………………………(address)

……………………………………………………………………………………………………………………………………………

The following:

…………………………………………………………………………………………………………(description of goods)

…………………………………………………………………………………………………………………………………………

Declare that:

I suffer from Seasonal Affective Disordernt and the product is for domestic and personal use:

…………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………

I am receiving from Morton Medical Ltd. , 3-9 Broomhill Road, London, SW18 4JQ. United Kingdom.

I declare that the goods are being supplied to me for domestic or my personal use.

Signed:…………………………………………………………       Date:……………………….

If the individual is unable to sign because of their disability or illness – a third party may sign on behalf of the named person. If you are a third party signing the above on behalf of someone else, please give you details below:

Name……………………………………………………………………………………………………

Address………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………

Relationship to the named person above?………………………………………………………………………………