Voucher

Fuel Voucher Referral Form
Referrers Details
Your Organisation*
Your Name*
Your Telephone*
Your email*
example@example.com
Date of Submission

DayMonthYear
Date
By completing the form below you confirm your client has granted you permission to enter their personal data, and for us to speak to them or leave a message. Information on this form will be held and used by Energy Projects Plus for the purposes of providing the assistance requested. This information will not be given to other agencies without your client’s prior approval. Any information provided will be held and used in accordance with the General Data Protection Regulation. Our Privacy Policy can be accessed here.
Client Details
Full name*

First NameLast Name
Address*
Town & Locality
Post Code*
Local Authority*
Telephone*
Alternative Telephone
Email
example@example.com
Who is/are the energy supplier, if unknown, please enter “unknown”*
Essential Requirement 1*

The Client is responsible for paying their gas and/or electric bills
Essential Requirement 2*

The client pays for their electricity and/or gas via a prepayment meter.
Essential Requirement 3*

The client is close to, or already using, or has already expended the emergency credit facility on their prepayment meter.
Essential Requirement 4*

The client requires financial support to top-up their prepayment meter.
Please let us know about any vulnerabilities

Health condition affected by coldLow incomeBenefitsOther vulnerabilities, please describe below
Optional Notes
Energy Projects Plus makes at least three attempts to contact each new client. Once we’ve spoken with your client, we will process an application for a fuel voucher if appropriate. Please note, it can take approximately 24 hours for a fuel voucher to arrive from that point. For help completing this form, or if you have any other queries, call the Save Energy Advice Line free on 0800 043 0151. Lines are open 9am-5pm, Monday-Friday
(apart from bank holidays)
File Upload if required. Please display the name of the client in the file name, thank you.

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Fuel Voucher Referral Form

Referrers Details

Client Details