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CHS Apply Now
CHS Apply Now
Get Addresses by Postcode
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Application Stage 1
Personal Details
Title
*
Mr
Mrs
Miss
Ms
Mx
Sir
Dr
Professor
Lord
Lady
Prefer not to say
First Name
*
*
Last Name
*
*
Email
*
*
*
Contact Number
*
*
Alternative Contact Number
*
Postcode
*
*
Address
*
*
Town
*
*
How did you hear about us?
*
CHS Website
Age UK
Google Search
Leaflet
Letter
Local Authority
Newsletter/Newspaper
Quick Form
Radio
Refer a Friend
Social Media
Staffordshire Socials
Word of Mouth
Beat The Cold
Citizens Advice Bureau
Nottinghamshire Energy Partnership
Other
City Energy Website
Social – CHSFB
Leaflet – CHSStaff01
Letter – CHSStaff01
Social – LAStaff
Letter – LAStaff01
Leaflet – CHS ECO
Refer a Friend – CHS
Poster – CHSStaff01
Banner – CHSInstallV1
SSDC Website
Google ads
Farmart Magazine
CHS Lead – Door to Door
GP Referral – CHS24
CHS Sales – Zaki
CHS Sales – Steve
CHS Sales – Tom
Please provide details of where you heard about us
*
Application Submitted?
No
Yes
Property Details
Property Type
*
Flat
Maisonette
House - detached
House - semi-detached
House - mid-terrace
House - end-terrace
Park Home
Bungalow - detached
Bungalow - semi-detached
Bungalow - mid-terrace
Bungalow - end-terrace
No of Bedrooms
*
*
*
Property Ownership Status
*
Owner-Occupier
Private Rented
Social Rented
Leasehold
Landlord Name
*
Heating Type
*
Gas Boiler
LPG Boiler
Oil Boiler
Gas Room Heaters
Air Source Heat Pump
Electric Boiler
Electric Storage Heaters
Electric Room Heaters
Solid Fossil Fuel Boiler
Solid Fossil Fuel Room Heaters
No Heating
How old is your heating system?
*
Less than 5 years
5 - 10 years
10 - 15 years
15 - 20 years
20 years plus
Unknown
Existing Measures Installed
Eligibility
Are you in receipt of Government Benefits?
Yes
No
Are you or a member of your household currently in receipt of one of the following benefits?
*
Not Applicable
Income Based Income Support
Housing Benefit
Universal Credit (UC)
Child Tax Credit (CTC)
Working Tax Credit (WTC)
Income Based Jobseekers Allowance (JSA)
Income Based Employment & Support Allowance (ESA)
Income Support (IS)
Pension Credit Savings Credit (PCSC)
Pension Credit Guarantee Credit (PCGC)
Severe or long-term ill-health conditions?
*
Annual Gross Household Income
*
*
Please tell us your annual gross household income. Enter numeric values only.
How many adults living in the property (aged 18 or over)?
*
1
2
3
4
5+
Please confirm your consent for Community Home Solutions Limited to share your details for the purpose of progressing your application and to comply with Scheme/Funder requirements.
*
No
Yes
Application Details
Application Number
CHS Application Number
Application Status
