Personal details:

Title:

Mr, Mrs, Dr etc.

Forename:

Surname:

*

Date of Birth:

Day - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month - January February March April May June July August September October November December Year - 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992

Telephone No:

Mobile:

Address:

Postcode:

Email:

To qualify for free insulation you must meet one of the following criteria. Please note that you will be asked to provide evidence of this when a surveyor calls.

Please indicate which is applicable to you:

Single person household with income or pension less than £18,000 gross

Couple or single parent household with income or pension less than £25,000 gross

Single person household / Couple with an income / pension of less than £30,000 gross AND over 70

 Tenancy:

Are you a:

Home Owner

Private Tenant *

* If you are a private rented tenant please complete below:

Landlord's Name:

Landlord's Address:

Landlord's Telephone:

 Requirements:

Do you require:

Loft Insulation

Cavity Wall Insulation

Both

Where did you hear about this offer?

Please choose NIE Energy website Energy Saving Trust advice centre Radio Local paper Age NI Newsletter Family or Friends Other

Click to submit  

Submit!