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Do you personally suffer from sickle cell/thalassaemia/other anemia?*

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Do you agree for Citizens Advice Birmingham to store your personal information?*

I consent to information being stored

Citizens Advice Birmingham processes information provided online, which includes your personal information, and stores this securely on a shared electronic management system accessed by members of the Citizens Advice Service. Personal information is any information which can identify you (e.g., name, address, date of birth). By completing and submitting this online form, you are providing consent for your personal information to be stored. If you do not wish your details to be held, please contact our telephone service on 0808 278 7990.

Do you agree for Citizens Advice Birmingham to store your personal information?*

I consent to special category data being stored

Special category data includes the following: personal data revealing racial or ethnic origin; political opinions; religious or philosophical beliefs; trade union membership; data concerning health; data concerning a sexual orientation. You may submit this form without consenting to special category data being stored, but this may affect our ability to provide you with the most appropriate advice possible.

Do you give your permission to share information for collecting feedback and permission for authority to act?*

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Contact permissions

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Please check the relevant boxes to let us know how we may leave you messages.

Title*

Name*

Date of Birth*

Postcode*

Address*

Contact telephone number*

What is the best to time contact you (between 9am-5pm)?*

Email*

Confirmation Emailexample@example.com

Gender*

Ethnicty*

Housing Type*

Household Type*

Employment status*

Nationality*

Please write 'Prefer not to say' if you do not wish to disclose this information.

First Language if not English*

Please write 'Not Applicable if your first language is English or 'Prefer not to say' if you do not wish to disclose this information.

Do you have any language requirements

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Please tell us what you need help with*

Please verify that you are human*