sgn - National Energy Action (NEA)

Unique ID

Referrer's Details

Name(Required)

First Last

Organisation(Required)

Phone(Required)

Email(Required)

Enter Email Confirm Email

Client's Details

Name

First Last

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

Phone(Required)

Can a message be left on this number?

Yes

Mobile Phone(Required)

Can a message be left on this number?

Yes

Customer's Date of Birth

Interpreting Service Required

Yes

Customers Preferred Spoken Language

Support

What type of support do your clients need?(Required)

Energy Advice

Benefits Advice

Water Debt Advice

Other (include more details in the ‘additional details’ section beloww

File Upload

Attach eligibility documents including your/your client’s latest fuel statement here.

Drop files here or

Max. file size: 2 MB.

Additional information

If there is any other information you think we should be made aware of please include it here. Please include information about the issue, any progress or actions already taken, any known deadlines or any sensitive matters to be aware of.

GDPR

By ticking the box below you confirm that:

• 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 below will be stored and processed according to NEA’s privacy notice

Please tick this box to confirm your understanding of the above.(Required)

I agree to the information above

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