Surveypoint

Q1

First name

Name*

Q2

Surname

Name*

Q3

Mobile number:*

Q4

Email address:*

Q5

Street Address

Address*

Q6

Suburb

Address*

Q7

City

Address*

Q8

Postcode

Address*

Q9

Country

Address*

Q10

Date of Birth:*

Q11

How do you identify yourself:*

Female

Transgender

Gender neutral

Q12

Single Parent:*

Yes

No

Q13

Name of the organization that referred you:*

Q14

MSD (WINZ) Client number (if any):

Q15

Have you secured a (Transition to Work) fee for this service from your Case Manager?

Yes

No

Q16

Is this your first or second dressing appointment with DFSA:*

First

Second

Q17

Are you booking a virtual dressing or visiting a DFSA showroom:*

A virtual appointment

Visiting our Manukau showroom

Visiting our Grafton showroom

Q18

This dressing service is for what purpose:*

Job Interview

Employment secured

Study Course

Court Appearance

Housing Interview

Q19

Ethnic Group:*

NZ European

Maori

Pacific Islander

Asian

Caucasian/European

Q20

Age Range (in years):*

Below 18

18 - 24

25 - 30

31 - 40

41 - 50

Over 50

Q21

Clothing size for tops/jackets:*

8 - 10

12

14

16

18

20+

Q22

Clothing size for hips e.g. pants/skirts/dresses:*

8 - 10

12

14

16

18

20+

Q23

Shoe size indication:*

5 -6 (35-36)

7 (37)

8 - 9 (38-39)

10+ (40+)

Q24

Permission to contact you regarding our Career Centre employment support programme:*

Yes

No

Q25

Permission to add you to our mailing list for information on DFSA community sales, news and events:*

Yes

No

Q26

Media preference for service:*

Facetime

Messenger

Whats App

Q27

Provide your media User Name for us to connect for this appointment:*

Q28

I consent to the above authorization and agreements:*

Yes

No

Q29

Client Dressing Service -Form Fill

First name

Surname

Mobile number:*

Email address:*

Street Address

Suburb

City

Postcode

Country

Date of Birth:*

How do you identify yourself:*

Single Parent:*

Name of the organization that referred you:*

MSD (WINZ) Client number (if any):

Have you secured a (Transition to Work) fee for this service from your Case Manager?

Is this your first or second dressing appointment with DFSA:*

Are you booking a virtual dressing or visiting a DFSA showroom:*

This dressing service is for what purpose:*

Ethnic Group:*

Age Range (in years):*

Clothing size for tops/jackets:*

Clothing size for hips e.g. pants/skirts/dresses:*

Shoe size indication:*

Permission to contact you regarding our Career Centre employment support programme:*

Permission to add you to our mailing list for information on DFSA community sales, news and events:*

Media preference for service:*

Provide your media User Name for us to connect for this appointment:*

I consent to the above authorization and agreements:*

Date:*