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2. Section A
4. Full Name*
5. Date
7. Title (if applicable)
8. Business Name (if applicable)
10. Phone Number*
11. Email Address*
12. Best Way to Contact

    1. Phone
    2. Email
14. Website
16. Address*
18. Business Address (if applicable)
20. City*
21. State*
22. Zip Code:*
24. How did you hear about the program

    1. Personal Referral
    2. Newsletter
    3. City's website

    1. Letter/Flyer
    2. Social Media
    3. Other
26. Seeking the following benefits/ Information (Check all that apply)*

    1. No-Cost Home Energy Assessment
    2. Heating, ventilation and air conditioning( HVAC)
    3. Heat Pumps

    1. No-Cost Energy Assessment for Businesses
    2. Other
28. If Other, please specify below:
32. Section B (for residents only)
34. Type of Home you live in:

    1. Single-Family
    2. Multi-Family
    3. Townhouse
    4. Condominium
    5. Apartment
36. Do you own or rent?

    1. Own
    2. Rent
38. Name of Utility Company:
40. Please detail below your specific energy needs/ questions:
44. Section C (for business owners only)
46. What type of business do you operate?

    1. Retail
    2. Restaurant
    3. Office

    1. R&D
    2. Manufacturing
    3. Warehouse

    1. Daycare
    2. Other
48. If Other, please specify below:
50. Do you rent or own?

    1. Rent
    2. Own

    1. Sublease
52. Name of Utility Company:
54. Please detail below your specific energy needs/ questions:
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field