New Gas Connection ApplicationPlease complete the form below to apply for a gas connection at your property.PART AName:*Address:*Postcode:*Telephone:*Email:* Do you need us to contact you via different details than those supplied above?* Yes NoCorrespondence Address:*Correspondence Postcode:*Correspondence Telephone:*Do you live at the gas supply address?* Yes NoPLEASE NOTE: You must live at the house to claim a grant.2. Are you currently:Building your house?* Yes NoRenovating your house?* Yes No3. Your residency details:A. Are you the property owner?* Yes NoB. An occupier of the property (you live in home but do not own or rent it)?*If answering 'Yes', please provide us with evidence of residency. Yes NoC. A private tenant?* Yes NoD. The tenant of a housing association or local authority?* Yes NoConsent Form – What is consent, when is it required and who obtains it?It is the responsibility of the customer to obtain any required consents and carry out all negotiations. Written proof of consent is required before work can be carried out.Consent is written permission from a property owner to enter, excavate and install a gas service within their land. It is required when any low pressure service, less than 63mm diameter, crosses third party land. This can include the siting of a meter box or the installing of pipework between the meter and the customer’s appliances.To be completed by you, the requester of the work:Your Order Number (if applicable):Your Name:Organisation:House Number:House Name (if applicable):Street name:Town/ City:Postcode:Phone (Day):Phone (Evening):Email Address: Consent required from the owner of property:House Number:House Name (if applicable):Street name:Town/ City:Postcode:Please indicate what you require consent for:Require consent forThe laying of a gas pipe across the private ground The laying of a gas pipe across the private ground(and/or)The installation of a gas meter box on the wall The installation of a gas meter box on the wall(and/or)The laying of gas pipe across the building wall or inside the property The laying of gas pipe across the building wall or inside the propertyTo be completed by the consent giver:Your Name:Organisation:House Number:House Name (if applicable):Street name:Town/ City:Postcode:I, being the:Consent giver type Owner of the property Acting agent on behalf of the owner of the property Appointed contractor of the owner of the propertyProvide consent for:Consent - The laying of a gas pipe across the private ground The laying of a gas pipe across the private ground(and/or)Consent - The installation of a gas meter box on the wall The installation of a gas meter box on the wall(and/or)Consent - The installation of a gas meter box on the wall The installation of a gas meter box on the wallAt property:House Number:House Name (if applicable):Street name:Town/ City:Postcode:Date:For tenants - please provide Landlord’s details below:Landlord Address:*Landlord Postcode:*Landlord Telephone:*4. How many people (including children) are in your household?Number of adults living in the property:Number of children under the age of 14:Number of children over the age of 14:Are you over the age of 70? Yes NoIf yes please provide date of birth.5. Is anyone usually at home during the day? Yes No6. a. What is the combined income over a year, after any tax and National Insurance is paid, of all the people living in your home? (Please include all wages, benefits, pensions, interest on savings or any other money received – after tax and any National Insurance payments.)How would you like to enter your income? By week By month By yearYour income each week (after tax):Your income each month (after tax):Your income each year (after tax):6.b.What are your housing costs and do you receive any help to pay your housing bills?Housing costs each year:Mortgage:Rent:Council Tax:Housing help each year:Mortgage support:Housing Benefit:Council Tax Reduction:7.a. How do you pay for your household energy?* Quarterly Direct Debit Pre-paymentPART BStatement of BenefitsYour benefitsPlease check the box if you or your partner claim any of the following benefits: Pension Credit (Guarantee Credit Element) Income Based Job Seeker’s Allowance Working Tax Credit Child Tax Credit Income Related Employment and Support Allowance Income Support Universal Credit Disability Living Allowance Personal Independent Payment Attendance Allowance Carer’s Allowance Severe Disablement Allowance Industrial Injuries Disablement Benefit Child Benefit (income threshold applies) War Pensions Mobility Supplement Constant Attendance Allowance Armed Forces Independent PaymentMeans Tested Benefit Income-based Jobseeker’s Allowance Income-related Employment and Support Allowance Income Support Pension Credit Tax Credits (Child Tax Credit and Working Tax Credit) Housing Benefit Council Tax Support Social Fund (Sure Start Maternity Grant, Funeral Payment, Cold Weather Payment) Universal CreditPlease choose which reference you wish to provide: National Insurance Number Benefit reference numberNational Insurance Number:*Benefit reference number:*PART C1. When was your home built?* Pre 1900 1900-1929 1930-1949 1950-1966 1967-1975 1976-1982 1983-1990 1991-1995 1996-2002 2003-2006 Post 20072. What type of home do you have?* House Bungalow Flat Maisonette2b. Is your home:* Detached Semi-detached End terrace Mid-terrace2b. Floor level:* Top floor Mid floor Ground level BasementHow many storeys does your home have?*How many bedrooms in the property?*How much of your home is double glazed?* None Some (up to 25%) Half (50%) Most (75%) All (100%)What type of roof does your home have?* Flat Pitched - No Access Pitched Roof Pitched (Thatch) Pitched / Loft Access Another Dwelling AboveAre your external walls:*If 'other' please specify. Solid Brick Cavity Timber Frame Concrete Stone Does your property have a registered EPC? Yes NoIf 'yes' please confirm the registered EPC ratingPART D1. What is your main heating system in your home?*If 'other' please specify. Standard Boiler Warm Air System Condensing Boiler Storage Heaters Combi Boiler Room Heaters / Fires Condensing - Combi Boiler Back Boiler Make of heating system:2. What fuel does your main heating system use?* Anthracite Back Boiler Coal (open fire in grate) Coal (closed room heaters) Wood chips Wood logs Wood pellets (bulk supply) LPG/Bottled gas LPG Bulk (Tank) Heating oil Electricity – on peak Electricity – off peak (night storage heaters)3. What controls does your heating system have?* No controls Heater/Fire thermostat Programmer and Room thermostat Radiator valve thermostat Manual Charge Control Automatic Charge Control4. How do you heat your hot water in your home?*If 'other' please specify. No controls Heater/Fire thermostat Programmer and Room thermostat Radiator valve thermostat Manual Charge Control Automatic Charge Control Electric Immersion on/off peak Electric Instantaneous 5. 5. Do you have a health condition made worse from living in a cold home? Yes NoPlease visit www.affordablewarmthsolutions.org.uk/qualifying-criteria/ for examples of such conditionsPART E: ConsentHousehold Statement* I can confirm the information I have provided is correct and to the best of my knowledge. I give permission for the information in this form to be used by Affordable Warmth Solutions CIC for the purpose of this project.The information may be transferred, processed and used for reporting to Ofgem and Cadent Gas. This information will not be given to other companies or agencies without your permission and will be held in accordance with the General Data Protection Regulation (GDPR) 2018 and any successor legislation to the GDPR or the Data Protection Act 1998.