Winter Warmth Pack application form

Through our Better Days programme, we are supporting customers who need additional support this winter. To be eligible for our free Winter Warmth Pack, please confirm:

They are an Orbit customer

Are over the age of 18

Have not have received more than one Winter Warmth Pack in last 6 months

Is in fuel poverty or financial difficulty

Privacy statement

Orbit is collecting your information (‘personal data’) so that we can manage and support our relationship with you, comply with legal obligations, improve our services and achieve our legitimate business aims. We are committed to complying with data protection legislation when handling your data. You have rights around your data, including the right to access your data, and to object to the way it is processed. For more information on how and why we process your data, and how to exercise your rights, please see our full Privacy policy.

By completing this form on behalf of another person, you are confirming that they have given you permission to request support from Orbit and our partner, Ehtstat Ethical. You are confirming that they have given consent for their name, address and contact details to be stored by Orbit and our partner, Ethstat Ethical. *

Yes, I have permission

Are you an Orbit employee? *

Yes
No

I have made a referral to CAMM (Energy Support)

Yes
No

Is the person you are referring an Orbit customer? *

Yes
No

Is the customer in fuel poverty or financial difficulty? *

Yes
No

Sorry, this service is only available to Orbit customers

Please do not click the 'Submit' button as your request will not be actioned.

Sorry, this customer does not meet the criteria

Please do not click the 'Submit' button as your request will not be actioned.

Customer's first name *

Customer's last name *

Customer's address *

Customer's postcode *

Contact number *

Email address

Name of employee *

Your job title *

Your email address *

Your phone number *

Is the customer housed with support or non-housed with support? *

Housed with support
Non-housed with support

We would like to gather the following information for equality, diversity and inclusion. By doing this, we can monitor whether our service is reaching hard to reach groups and help us to identify gaps in our diverse customer base. If you choose not to answer the following questions, your application will not be affected. Are you happy to proceed? *

Yes
No

Consent for storing submitted data and Ethstat to return information to Orbit *

Yes, I give permission to store and process my data