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Application Form - Free Storage Heaters

Replace Old Storage Heaters FREE

Your Data Will Only Be Used For Obtaining Government Funded Grants – We Do Not Sell On To Other Parties.

Please Do Not Apply If You Are Not Contactable By Phone !

Free Storage Heaters Survey

Step 1 of 14

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What Is Your Current Main Heating*
- Old Electric Storage Heaters
- Gas Boiler & Radiators
- Warm Air System
- LPG Boiler
- Oil Boiler
- Coal Fire
- Wood Burner
- No Heating System Present

Would You Like A Heat Pump If You Are Eligible?*
- Yes -Free Air Source Heat Pump If Possible
- No Interest In Heat Pump
Larger Electric Heated Homes May Be Eligible For A FREE HEAT PUMP

Would You Like Free Central Heating If Possible?*
- Yes -Free Central Heating If Possible
- No Interest In Central Heating

Which Benefit Do You Receive?*
- Housing Benefit
- Universal Credit
- Pension Credit Guarantee
- Tax Credits
- Job Seekers / Income Support
- Child Benefit
- Employment & Support Allowance
- No Benefits - MIDLANDS POSTCODES ONLY

Do You Have a Gas Meter Fitted ?*
- A Gas Meter Is Fitted
- No Gas Meter Is Fitted

Which FREE Insulation Are You Interested In ?*
- I Would Like A Whole House Check
- My Home Is Fully Insulated
Insulation must be fitted to enable funding for heating upgrades.

What Is Your Housing Status?*
- Home Owner
- Landlord
- Private Tenant
- Shared Ownership
- Council Tenant -NOT ELIGIBLE
- Housing Association Tenant -NOT ELIGIBLE

What Is Your Property Type*
- Top Floor Flat
- Ground Floor Flat
- Maisonnette
- Mid Terraced House
- End Terraced House
- Semi Detached Bungalow
- Semi Detached House
- Detached House
- Detached Bungalow
- Park Home

How Many Bedrooms Do You Have*
- One Bedroom
- 2 Bedrooms
- 3 Bedrooms
- 4 Bedrooms +

Please Enter Your Postcode*
House Number AND Ist Line Of Address*

Benefits Claimants Full Name*
Benefits Claimants Date Of Birth*

Your Phone Number*
2nd Phone Number OR Email Address*

Please Provide A Password*
Please provide us with a password to assist you properly Favourite Pet Or Favourite Group. Thank you.

Best Time To Phone You To Book Your Free Survey*
- Any Time
- Morning
- Afternoon
- Early Evening
Please Do Not Submit This Form If You Are Not Contactable By Phone GENUINE APPLICANTS ONLY PLEASE

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