Lemon Aid Low Energy Applicance Referral Form (Client)Please enable JavaScript in your browser to complete this form.Customers Details Please Select Your RegionNorth AyrshireEast AyrshireDumfries & GallowayName *FirstLastCustomer Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeCustomer Phone *United States +1United States+1United Kingdom+44Afghanistan+93Albania+355Algeria+213American Samoa+1Andorra+376Angola+244Anguilla+1Antigua & Barbuda+1Argentina+54Armenia+374Aruba+297Ascension Island+247Australia+61Austria+43Azerbaijan+994Bahamas+1Bahrain+973Bangladesh+880Barbados+1Belarus+375Belgium+32Belize+501Benin+229Bermuda+1Bhutan+975Bolivia+591Bosnia & Herzegovina+387Botswana+267Brazil+55British Indian Ocean Territory+246British Virgin Islands+1Brunei+673Bulgaria+359Burkina Faso+226Burundi+257Cambodia+855Cameroon+237Canada+1Cape Verde+238Caribbean Netherlands+599Cayman Islands+1Central African Republic+236Chad+235Chile+56China+86Christmas Island+61Cocos (Keeling) Islands+61Colombia+57Comoros+269Congo - Brazzaville+242Congo - Kinshasa+243Cook Islands+682Costa Rica+506Croatia+385Cuba+53Curaçao+599Cyprus+357Czechia+420Côte d’Ivoire+225Denmark+45Djibouti+253Dominica+1Dominican Republic+1Ecuador+593Egypt+20El Salvador+503Equatorial Guinea+240Eritrea+291Estonia+372Eswatini+268Ethiopia+251Falkland Islands+500Faroe Islands+298Fiji+679Finland+358France+33French Guiana+594French Polynesia+689Gabon+241Gambia+220Georgia+995Germany+49Ghana+233Gibraltar+350Greece+30Greenland+299Grenada+1Guadeloupe+590Guam+1Guatemala+502Guernsey+44Guinea+224Guinea-Bissau+245Guyana+592Haiti+509Honduras+504Hong Kong SAR China+852Hungary+36Iceland+354India+91Indonesia+62Iran+98Iraq+964Ireland+353Isle of Man+44Israel+972Italy+39Jamaica+1Japan+81Jersey+44Jordan+962Kazakhstan+7Kenya+254Kiribati+686Kosovo+383Kuwait+965Kyrgyzstan+996Laos+856Latvia+371Lebanon+961Lesotho+266Liberia+231Libya+218Liechtenstein+423Lithuania+370Luxembourg+352Macao SAR China+853Madagascar+261Malawi+265Malaysia+60Maldives+960Mali+223Malta+356Marshall Islands+692Martinique+596Mauritania+222Mauritius+230Mayotte+262Mexico+52Micronesia+691Moldova+373Monaco+377Mongolia+976Montenegro+382Montserrat+1Morocco+212Mozambique+258Myanmar (Burma)+95Namibia+264Nauru+674Nepal+977Netherlands+31New Caledonia+687New Zealand+64Nicaragua+505Niger+227Nigeria+234Niue+683Norfolk Island+672North Korea+850North Macedonia+389Northern Mariana Islands+1Norway+47Oman+968Pakistan+92Palau+680Palestinian Territories+970Panama+507Papua New Guinea+675Paraguay+595Peru+51Philippines+63Poland+48Portugal+351Puerto Rico+1Qatar+974Romania+40Russia+7Rwanda+250Réunion+262Samoa+685San Marino+378Saudi Arabia+966Senegal+221Serbia+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1Slovakia+421Slovenia+386Solomon Islands+677Somalia+252South Africa+27South Korea+82South Sudan+211Spain+34Sri Lanka+94St. Barthélemy+590St. Helena+290St. Kitts & Nevis+1St. Lucia+1St. Martin+590St. Pierre & Miquelon+508St. Vincent & Grenadines+1Sudan+249Suriname+597Svalbard & Jan Mayen+47Sweden+46Switzerland+41Syria+963São Tomé & Príncipe+239Taiwan+886Tajikistan+992Tanzania+255Thailand+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad & Tobago+1Tunisia+216Turkey+90Turkmenistan+993Turks & Caicos Islands+1Tuvalu+688U.S. Virgin Islands+1Uganda+256Ukraine+380United Arab Emirates+971United Kingdom+44United States+1Uruguay+598Uzbekistan+998Vanuatu+678Vatican City+39Venezuela+58Vietnam+84Wallis & Futuna+681Western Sahara+212Yemen+967Zambia+260Zimbabwe+263Åland Islands+358Customer EmailCustomer Family SizeCustomer Income DetailsEmployedBenefitsPensionIn What Way Would You/Customer Benefit From One Of The Low Energy Applicance Available?Please provide as much detail as possibleWhich Low Energy Applicance Would You Benefit From Most?MicrowaveAir FryerSlow CookerAre you currently off supply?YesNo Do you currently have arrears with your energy supplierYesNoAccomodation DetailsRented PropertyOwner/OccupierSignature *By typing your name in this box you are giving permission for the provision of information relating to my advice needs to the Citrus Energy Team. I understand and agree that all information given will be available to both of these parties at all times for the purpose of assisting me in my Energy bills.Date of SubmissionToday's DateSubmit