Consumer Advice by Email Please note, fields marked with the red asterisk are mandatory. If you are human, leave this field blank. KEEPING RECORDS ABOUT YOUR CASE We need to record information about you to help with your enquiry. We have a legitimate interest to do this. Please let us know if you’d like more information about how we’ll use your data. When we record and use your personal information we: ● only access it when we have a good reason ● only share what is necessary and relevant ● don’t sell it to commercial organisations Your Title * Mr/Mrs/Miss/Ms etc. Your Full Name * Date of Birth * Gender Male Female Unknown/declined to reply Ethnicity * White Northern Irish White Irish White Scottish White English Arab White Other White Welsh Roma/Gypsy/Traveller Mixed - White & Black Caribbean Mixed - White & Black African Mixed - White & Black Other Mixed - White & Asian Asian/Asian British - Indian Asian/Asian British - Pakistani Asian/Asian British - Bangladeshi Asian/Asian British - Chinese Asian/Asian British - Other Black/Black British - Caribbean Black/Black British - African Black/Black British - Other Unknown Decline to Reply Nationality * Telephone Number * Can we leave a message? * yes no Do you have a disability or long term health condition? * yes no In order to comply with data protection requirements emails containing sensitive, personal information have to be encrypted. Encryption ensures the content of a message remains secure while in transit. If you are sent an encrypted message from us it will come with a link that you will need to click on to unencrypt the message. This will take you to Egress Switch where you will be asked to register your name and a password of your choosing to read the email. You will only ever have to do this once. The service is free and no software is installed on your computer/device. Email Address * Enter Email Confirm Email Address * Confirm Email House Number/Name * Address Home Postcode * Can we write to this address? * yes no Work Address Work Postcode Have you contacted us before? Yes No Have you visited the Citizens Advice website for more information about your enqury? Yes No Are you (or your partner/spouse) in receipt of any benefit? Yes No What has happened? * Please include if possible, dates including the date the problem started, the last time the event occurred, date of dismissal if appropriate, dates of any hearings. What are you hoping we can do for you? * Please give as much information as possible including relevant dates etc Terms & Conditions * By checking this box, you confirm that you have read and understood our terms and conditions. Yes, I consent to you holding information on my (please tick all of those you agree to) * Ethnicity Health Condition Religion Sexual orientation Trade Union membership Do not Record this information I/we give my/our consent to the Citizens Advice Service to share my/our contact information with an independent organisation for the purpose of satisfaction monitoring * Yes No reCAPTCHA