Energy Survey
Please take a few minutes to tell us more about you
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Do you own or rent the home you live in?
*
Own
Rent
What best describes your monthly electric bill?
*
$100+
$200+
$300+
$400+
What is your household annual income range?
*
$9,999 or less
$10,000-$24,999
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000 or more
What is your employment status?
*
Employed full time
Employed part time
Self-employed
Unemployed
Retired
Which answer best describes your credit?
*
500 or below
500 to 600
600 to 650
650+
How committed are you about reducing your utility bills?
*
Not Committed
1
2
3
4
5
6
7
8
9
Extremely Committed
10
1 is Not Committed, 10 is Extremely Committed
Which of the following would describe your desire to make your home more energy efficient?
Save Money
Be Energy Independent
Utilize Federal and State Tax Credits/Rebates before they go Away
Increase the Value of your Home
Other
What Energy Efficient Products are you Interested in for your home?
Solar panels
New HVAC System
Energy Efficient Windows
Insulation
Other
Which of the followings would influence your decision to purchase?
Price
Quality
Value
Brand
Other
We know your time is valuable so at the completion of the energy consultation we have a gift card for you as a token of our appreciation ? (Select the gift card you prefer)
Visa Gift Card
Amazon Gift Card
Walmart Gift Card
Submit
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