Priority Services Register sign up

Your name

TitleFirst nameSurname

Your address

First line of your address

Second line of your address

City

Postcode

Your date of birth

DayMonthYear

Your email

example@example.com

Your phone number

Alternative phone number

Preferred method of contact

Are you deaf or hard of hearing and use only text or another method to stay in touch?

If you require a interpreter, please specify what language below:

Would you like to nominate another contact to act on your behalf in case of a power cut? This could be a close family member or friend.

Nominated contact first name

Nominated contact first nameNominated contact surname

Address

First line of nominated contact address

Second line of nominated contact address

City (nominated contact)

Postcode (nominated contact)

Nominated contact email

example@example.com

Nominated contact phone number

Do you or anyone in your household rely on electricity for home medical equipment?

Please tick all the reasons that are applicable to you or someone in your household:

If you answered 'Other reason' in the list above, please tell us more here.

Please tick the box if you or someone in your household fits into any of the categories below:

If you answered 'Other condition' in the list above, please tell us more here.

Temporary registration

If you answered 'Recent change of circumstances' in the list above, please provide details below.

Would you benefit from your bill being in a different format?

Please provide us with any other relevant information:

If you would like your supplier to use a confidential phrase when they visit your home, please enter one here:

Data Protection

The information you supply on this form will be stored by the Centre for Sustainable Energy (CSE) and shared with one or more of the following: National Grid (NG), Scottish & Southern Electricity Networks (SSEN), your water utility, your energy provider. This will be done solely for the purpose of adding you to that utility provider's Priority Services Register (PSR).

Any of the organisations named above may in turn need to pass your details to a third party such as the British Red Cross, local authority or emergency services, in order to provide you with priority services.

CSE, SSEN, NG. your water utility or energy provider will not use or pass your details to a third party for marketing purposes. If you have a nominated contact, you are giving your explicit consent for NG, SSEN, your water utility or energy provider to talk to your nominated contact on your behalf when providing priority services. This may mean NG, SSEN, your water utility or energy provider will share information about you and your electricity or water supply with them.

If you are a NG customer in South Wales or the Midlands we will need to pass your details on to our partners at the Energy Saving Trust (Wales) or Citizens Advice (Midlands) for the purposes of signing you up to the PSR and providing additional advice if you have requested it.

I understand

Do you struggle with bills or staying warm at home? Please let us know if you would like a member of the Home Energy Team to contact you to provide additional advice and support

Where did you hear about us?

If you answered 'Somewhere else' in the list above, please tell us where here.