Energy Referral Form - Citizens Advice Bury & Bolton

Company

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Energy Advice Sign Up

Please complete all sections of this form.

Date Of Referral(Required)

If you are completing this sign up on behalf of another person, please state your name and organisation below

For the remainder of this form, 'you' refers to the client

Client's Personal Details

First Name(Required)

Surname(Required)

Date Of Birth (If unknown please put 01/01/1900)(Required)

Contact Details

Please fill out as much information as possible so we can contact you.

Mobile Phone Number(Required)

Home Phone Number

Email Address

COMMUNICATION METHODS NOT TO BE USED

Please state any communication methods you DO NOT want us to contact you using this box

Support Required

Energy Advice Required(Required)

Please provide any information below regarding particular advice that you require about energy.

If you have any supporting documents that relate to this case, please upload them here

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Max. file size: 512 MB.

Please let us know if you require any adjustments when you are contacted

Contact for Research and Feedback

We want to get feedback on the advice we provide. We will use this information to improve our service and inform our campaigns in a way that doesn’t identify you. If you want more detail about your rights and how we use your information you can read our privacy notice on our website.

Demographic Data

We want to ensure that we meet the aims and commitments set out in our EDI policy. This includes not discriminating under the Equality Act 2010. Completing the below questions helps us understand the diversity of our organisation and clients.

Ethnicity

Sexual Orientation