SAIL Client Consent and Authority to Act Form

SAIL – Client Consent and Authority to Act Form

At Seafarers’ Advice & Information Line (SAIL) we must ask for your consent to record, use, or share personal information, and for your authority to act on your behalf when we take action for you. SAIL is part of Citizens Advice.

Permission to record and use your personal information

To help with your enquiry we may need to record details of your case. We have to ask for your permission to record and use your personal information in this way.

I agree to the Citizens Advice service recording information about me

☐ Yes ☐ No

Permission to share information for collecting feedback

We want to make sure the service you receive meets your needs. To help us understand this and to improve our service, Citizens Advice may want to contact you at a later date to ask for your feedback. Sometimes we need a trusted research organisation to help us do that.

We need your permission to share your contact details with a trusted research partner. We only share what is absolutely necessary.

I agree to the Citizens Advice service sharing my personal information with organisations so that I can be contacted to give feedback

☐ Yes ☐ No

Authority to act

At SAIL we must ask for your authority to act on your behalf when taking action for you.

I authorise Seafarers’ Advice & Information Line to act on my behalf

☐ Yes ☐ No

concerning the issue(s) of ……………………………………………………………………………

Signed ………………………………………………………. Date …………………………………..

Name ……………………………………………………………………………………………………..

Address ……………………………………………………………………………………………………………………...

Mobile ……………………………. Email ……………………………………………………………………………….

SAIL has a complaints handling procedure. Please contact us for details. SAIL reference …………………….

Address - SAIL, 30 King William Walk, Greenwich SE10 9HUEmail –

SEAFARERS’ ADVICE & INFORMATION LINE (SAIL)

REFERRAL FORM

Please note that the form on Page 1 must be completed.

The remainder of the form is not essential but helps us give advice more quickly.

Section 1 –Seafarers Details
Family Name: / Forename(s): / Title:
Date of Birth: / Length Sea Service: / Address:
Postcode: / Phone No: / NI No:
Brief description of problem for referral :
Section 2 – Agreement to Referral
I / We agree for my/our details to be passed to S.A.I.L
Client’s Signature(s): / Date:
Section 3 – Referred By
Name: / Date:
Agency:
E Mail Address: / Contact Tel:
Section 4 – Housing (please tick)
□
Council/Housing Association / □
Owner
Occupier / □
Private
Rented / □
Military / □
Homeless / □
Other

PLEASE COMPLETE THE REST OF THIS FORM

Section 5 – Household (please tick)
□ Single / □ Married / □ Cohabiting / □ Widow/er / □ Divorced
Section 6 – Income from Benefits (please tick)
□ Income Support
□ Jobseekers Allowance
□ Universal Credit
□ Housing Benefit
□ Council Tax Support
□ Tax Credits
□ Pension Credit
□ Industrial Injuries Benefit / □ Employment & Support Allowance
□ Personal Independence Payment (or Disability Living Allowance)
□ Attendance Allowance
□ Carers Allowance
□ State Retirement Pension
□ Child Benefit
□ Occupational Pension
Section 7 - Employment
Client / Partner
Hours per week / Hrs: / Hrs:
Net Pay £
(State weekly/monthly) / £ / £
Section 8 – Children living in the household
Name / Date of Birth
Section 8 – Other adults living in the household
Name / Age / Status (employed /disabled) / Earnings £ (week/month)
yrs / - / £ -
yrs / - / £ -