Freephone: 0800 107 4101
Fax: 01376 531532
info@climateenergy.org.uk

Postal Address:
Climate Energy Ltd.
Countrywide House
Freebournes Road
Witham
Essex
CM8 3UN

Once you have completed this form your details will be passed to a specially selected contractor within you area, who will contact you within a few days. Additionally your details will be retained by us to monitor the progress of your application and eventually passed to a local authority or utility partner who will be funding your grant for you. These details will be used for no other purpose.

Customer Details - Referral Form

Date
DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM 01 02 03 04 05 06 07 08 09 10 11 12 YYYY 2010

Source of Enquiry
Where did you hear about Thurrock Energy? Local Authority Contractor Local Newspaper Drop Card Council Publication Mailshot Living in Havering Magazine Thurrock Gazette Dream 100 - Tendring Brentwood Council Living Magazine Yellow Pages Yell.com Dream 107.7 Radio Ad Thurrock Environmental Calendar Tendring Environmental Calendar Chelmsford Environmental Calendar Uttlesford Life Magazine Web Site Other Leaflet Google MSN

Are you or your partner over 70? Click Yes or No Yes No

Local Authority

Do You receive any benefits?
Select One Income Support Housing Benefit Council Tax Benefit Income Based Jobseekers Allowance Disabled Persons Tax Credit Working Tax Credit Attendance Allowance Disability Living Allowance war Disablement Pension Severe Disablement Allowance Child Tax Credit None

Do you own your own home?
Select One Own/Buying on mortgage Renting from Council Renting from Housing Association Renting privately

What type of house do you live in?
Select One Top Floor Flat Middle Floor Flat Ground Floor Flat Semi - Bungalow Detached - Bungalow Detatched Semi-Detatched Mid Terrace Mid Terrace with passage End terrace

How many bedrooms do you have?
Select One 1 2 3 4 5 6 6+

What is your main heating fuel?
Mains Gas Mains Electricity Oil Coal/solid fuel LPG Other

Is official state pension comprised of 50% more of your total house hold income?
Click Yes or No Yes No

What work do you require? (select all that apply)

Replacement Central Heating New Central Heating

Loft Insulation Only Cavity Wall Insulation Only

Loft & Cavity Wall Insulation Solar Hot Water

Other  (please specify)

If you are a Local Authority completing this form on behalf of a resident please tick here Please also give your name and contact number

Comments (please tell us here if you think you are eligible for any other schemes)