Gloucester Citizens Advice Bureau
To allow us to proceed with this email enquiry may we please ask you to complete the
The request for this information is in line with guidelines laid down by the Legal Services
Title – Mr / Mrs / Miss / Ms / Dr / Prof
Date of birth
Ethnic origin White British
Gender - Please indicate with an X Male female
Have you been advised by the Gloucester
Do you consider yourself disabled
Do you have long term health problems
Household type - Please indicate with an X
Single person Couple
Single with dependents Couple with dependents
Sing with non dependents Couple with non dependents
Employed under 30hrs p w Employed over 30 hrs p w
Self Employed Looking after a home
Monthly income profile – Please indicate with an X
Less than £400 £1500 - £1999
£400 - £599 £2000 - £2400
£600 - £999 £2500 - £2999
£1000 - £1499 £3000 or more
All our work is confidential, impartial, non-judgemental and free.
We keep your records on computer, and you may request to see these records.
Information supplied by you will be protected under data protection guidelines.
Bureau to complete
CASE Client Ref
May we remind you that email in not a secure method of communication.
Thank you for your assistance.