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Benefits Advice Referral Form

1Referrer Details
2Client Details
3Other information

There is currently a high demand for benefits advice services. We aim to respond to you within two weeks. Please complete the form below with all of the information that we have requested. It will help us more quickly deal with your enquiry.

Referrer's details

Name(Required)
Email address(Required)

Client's details

Client's name(Required)
Client's address(Required)
Client's email address (if they have one)
DD dash MM dash YYYY

Other information

Who supplies the client's gas and electricity(Required)
GAS
ELECTRICITY
 
Does the client use a prepayment meter?(Required)
Are you looking for a fuel top-up voucher for the client?(Required)
Max. file size: 10 MB.
What type of support does your client need?(Required)
Drop files here or
Max. file size: 10 MB.
    Consent(Required)

    • The client has given their permission for you to pass their information on to NEA.

    • You have explained the purpose of doing so and made the client aware that their information will be used by a member of the team to contact them.

    • You are processing the client’s data lawfully.

    • You are aware your personal details will be kept by NEA for the purposes of completing this referral.

    • Any information you supply will be stored and processed according to NEA’s Privacy Notice.

    Consent(Required)

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    National Energy Action (NEA)

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    Registered in England No. 1853927

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