Your details Title First name Surname Address Postcode Bristol Energy account number Telephone number (Without spaces) Email address To enable us to provide you with appropriate special services, please tick all the descriptions that apply to you, or someone in your household, and add any extra personal information which you would like to include. Special requirements Blind Partially sighted Hearing/speech difficulties (inc. Deaf) Stair life, hoist, electric bed Pensionable age Physical impairment Unable to communicate in English Developmental condition Unable to answer the door/restricted movement Dementia(s) Chronic/serious illness Restricted hand movement Families with young children 5 or under Mental health MDE electric showering Careline/telecare system Medicine refrigeration Oxygen use Poor sense of smell Additional presence preferred Electrical medical equipment Other (please specify) Special requirements Other (please specify) Preferred language Additional information (if required) Do you have electrical medical equipment or living aids in your home? Please tick any of the following medical equipment or living aids you have in your home. This could be for your own use or for someone who lives with you. Kidney dialysis machine, feeding pump or automated medication Heart/Lung & ventilator Nebuliser and apnoea monitor Oxygen concentrator Bath hoist Stair lift Please give details of any other medical equipment that depends on electricity Requested services Please tick any of the following services that you require. If selecting braille, large print or talking bills below, unfortunately you will also continue to receive communications in standard format. We are working to change this. Someone to come out and read your meter for you on a quarterly basis as you find it difficult to read your meter Braille bills/correspondence Large print bills/correspondence Talking bills/correspondence Duplicate bill/ statement to a third party What would you like your personal password to be? For added security you can have a personal password for use by Bristol Energy or our appointed electricity and gas agents who may wish to visit your home. Please write it here (must be six characters). Third Party Representative Please complete this section if you require another person to receive a duplicate of your energy bills/ statements from Bristol Energy and communicate with us on your behalf. Third Party Representative: Title Third Party Representative: First name Third Party Representative: Surname Third Party Representative: Address Third Party Representative: Postcode Third Party Representative: Telephone number (Without spaces) Third Party Representative: Email address Third Party Representative: Relationship to Bristol Energy customer Free gas safety checks If this is something you would be interested in, please complete the following information to confirm you eligibilty. Part 1: Please check the following boxes to confirm that all of the following criteria apply to you: I have not had a Gas Safety Check carried out during the previous 12 month period I am in receipt of means-tested benefits I am the owner of this property (if you are a tenant, your landlord is responsible for organising your annual gas safety check) If you have answered yes to all of the above, then you may be entitled to a free gas safety check. Please proceed to Part 2. Part 2: Please confirm if any of the below apply to you: I live alone and one of the following applies to me – I am of pensionable age, have a disability or am chronically sick I live with other people and everybody is either of pensionable age, disabled or chronically sick I live with a child under the age of 5 If you have answered yes to everything in Part 1, and one criteria in Part 2, then you are eligible for a free gas safety check and we will be in contact to discuss this with you soon. Remove me from the Priority Services Register I would like to be removed from the Priority Services Register
