RECEIVING BENEFIT—Please choose an option—Child Tax Credits and Working Tax CreditEmployment and Support Allowance (ESA)Jobseeker Allowance (JSA)Pension Credit Savings CreditPension Guarantee CreditIncome SupportUniversal CreditChild benefitHousing BenefitOthers
ARE YOU A HOME OWNER OR TENANT?—Please choose an option—Home ownerTenant
DO YOU HAVE GAS METER INSTALLED?—Please choose an option—yesNo
DO YOU HAVE RADIATOR INSTALLED?—Please choose an option—NoYes
TYPE OF EXISTING BOILER? —Please choose an option—Mains GasOilLPGElectric Storage HeatersElectrical HeatingSolid Fuel
BEST WAY TO CONTACT YOU?—Please choose an option—EmailPhone
WHAT IS YOUR CURRENT HEATING TYPE?—Please choose an option—GasElectric
WAS YOUR BOILER INSTALLED BEFORE 2003? *—Please choose an option—NoYesI don't have a boiler
FIRST NAME
LAST NAME
ADDRESS
EMAIL
PHONE NUMBER
PREFERABLE DATE
PREFERABLE TIME—Please choose an option—08:0009:0010:0011:0012:0013:0014:0015:0016:0017:00
TYPE OF SERVICE—Please choose an option—Free Boiler GrantFree Insulation GrantFree Heat Pump GrantFirst-Time Central Heating Grant
UPLOAD YOUR BOILER PICTURE
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