Become a Pepys Social Supermarket Member


Address


Who is your housing provider?


Are you in receipt of any benefits?

YesNo


What is your current employment situation?

WorkingJob SeekingRetiredOther

Other:

Are you interested in information about:

Housing adviceMoney/debt adviceEnergy billsTraining/employment supportCookery skillsOther? Please state

Other:

Do you ever struggle to pay:

RentEnergy billsOther essentials


Have you had to cut back on the amount you spend shopping?

YesNo


Do you ever run out of money by the end of the week?

YesNo


How many adults live in your household?


How many children live in your household?


Do you have any dietary requirements?


Your information will be used by 2000 Community Action Centre to give you updates about the project. We won’t share it with anyone outside of 2000 Community Action Centre, without your permission.



I declare that the information on this form is true and correct to the best of my knowledge.


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