361 Home Energy Call Form

1
Who are you applying for?* This field is required.
Myself
Myself
Someone else
2
What is your role or organisation?
Family Member
Family Member
Carer
Western Power Distribution
South West Water
Social Housing
Centre for Sustainable Energy
Health & Social Care
Partner Organisation
Other
3
What is your name?
First Name
Last Name
4
What is your email?
example@example.com
5
Applicant's Name* This field is required.
First Name
Last Name
6
Applicant's Email* This field is required.Please enter your email address
example@example.com
7
Applicant's Phone Number* This field is required.Your mobile, if you have one, is best
Area Code
Phone Number
8
Applicant's Home Address* This field is required.
Street Address
Street Address Line 2
City
County
Postcode
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Some questions to ensure you quality. Is this OK?* This field is required.70% of people living in North Devon qualify for our free home energy service, but we need to ask some questions about income, health and vulnerability to help us secure funding for your visit. Is this OK?
YESNO
10
Income Criteria* This field is required.Is ANYONE living at your address receiving one of the following? If so please select
None of the below
Child Tax Credit / Working Tax Credit
Child benefit
Pension Credit
Employment and Support Allowance
On a low income with children in the home
Jobseeker’s Allowance
Income Support
Universal credit
Carer’s Allowance
Housing Benefit or Council Tax Reduction
A Disability Benefit (incl. Attendance Allowance, DLA, PIP)
MoD administered benefits
11
Health Criteria* This field is required.Is ANYONE living at your address in one of the following situations? If so please select
None of the below
Respiratory condition (incl. COPD, asthma)
Cardiovascular condition
Neurological or neurobiological condition
Musculoskeletal conditions (incl. arthritis)
Blood conditions
Cancer
Moderate to severe mental illness (e.g., Depression, Anxiety)
Learning disabilities (e.g., Autism)
Autoimmune or immunodeficiency diseases (e.g. lupus, diabetes, HIV)
Terminally ill
Other illness exacerbated by cold (confirmed by GP)
In possession of a valid NHS Medical Exemption Certificate
12
Vulnerability Criteria* This field is required.Do any of the following situations relate to ANYONE living at your address? If so please select
None of the below
Recent bereavement
Victim of domestic violence
Moving in and out of homelessness
Recent immigrant or asylum seeker
Physical or sensory disability
13
Our home energy service is delivered in partnership with AgilityEco LEAP and we need to share your information with them* This field is required.I consent to 361 Energy sharing my contact information with AgilityEco who run the Home Energy Efficiency LEAP programme with the support of the council / housing association. I understand that a member of staff at the LEAP contact centre will telephone me to ask me further questions to confirm my eligibility for the scheme and arrange a home energy visit. I understand that this may include questions regarding my health and financial status and/or that of members of my household. I understand that my personal information will not be shared with or used by anyone outside this programme without my explicit consent unless the law allows for the sharing of information for the purposes of prevention and detection of crime or where I or another person would otherwise be at risk of serious harm. I consent for 361 Energy to retain my data and contact me in the future.
14
Address look up
15
When is the best time for us to call?* This field is required.
Weekday mornings
Weekday afternoons
Weekday evenings
Saturday morning
Saturday afternoon
Any time works
Should be Empty:

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