1. Church Details
Name of church/parish:
Address:
Contact name / position:
Contact Address:
Postcode:
Contact Email:
Ordnance Survey Ref:	*
Parish Website Address:

^*Optional but please supply this if you can as it will enable us to collate the information supplied with other data. There is currently no national record of church OS references.

2. Types of Energy used in Church / Church Buildings
	Electricity	Gas	Oil	Other
Total units/litres used in 12 months

3. Other
Does the church use floodlighting?	Yes		No
How much of the building?	Part		Whole
How frequently?	Days/Year		Hours/Day
Do you use a 'green' energy supplier?	Yes		No
Have you considered using a 'green' energy supplier?	Yes		No
Do you use any form of renewable energy?	Yes		No
If yes, what?
Have you considered using any form of renewable energy?	Yes		No
If yes, what?

The form will be sent to this Diocese's DEO/MoF Contact:  Choose... Bath & Wells Birmingham Blackburn Bradford Bristol Canterbury Carlisle Chelmsford Chester Chichester Coventry Derby Durham Ely Europe Exeter Gloucester Guildford Leicester Lichfield Lincoln Liverpool London Manchester Newcastle Norwich Oxford Portsmouth Ripon & Leeds Rochester Salisbury Sheffield Sodor & Man Southwark Southwell St Albans St Eds & Ips Truro Wakefield Winchester Worcester York

(If you want to make a copy, do that before sending.)

More information and resources from the Church of England’s National Environmental Campaign may be found on the website (www.shrinkingthefootprint.cofe.anglican.org) - or email:shrinkingthefootprint@c-of-e.org.uk

A PDF version of this form is also available.

Data Protection Act 1998
Contact details will be held by the diocesan contact for the Measuring our Footprint exercise only and will be used for the purposes of checking details on questionnaire forms only. It will not form part of the record of returns collated by the Church of England National Environment Working Group.