Electric Support 2023/24

Electric Support 2023/24

Applications from Applicants Only..
Applications only via this form unfortunately we are unable to accept applications by any other means i.e phone/Facebook. Many thanks for your understanding.

All applications will be assessed and those successful will be notified accordingly. Priority will be given to those deemed to be in most need.

We cannot guarantee assistance....
Name of Applicant*
Address*
Postcode*
Contact Number*
Email*
How many people in household*
Ages*
Including Parents
Circumstances of need.*
Have you received support of any nature within the past month?*

YesNo
Do you have family support?*

YesNo
Have you or your family a designated Social Worker?*

YesNo
GDPR

Information obtained for the purposes of this project will be retained for no longer than twelve months to meet with funders requirements. This information will not be shared with third parties.

You can request to have this information removed by contacting the GDPR OFFICER, Melmount Community Forum, 339 Ballycolman Estate, Strabane, BT82 9EH in writing.

By completing this form you agree to the retention of this information for the period stated above.

All information will be stored in line with GDPR requirements.
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty: