Weatherization Application

Weatherization Application

Applicant Information (click to expand)
Applicant Name*

First NameLast Name
Applicant Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Which does your house use?*

Natural GasLPFuel OilElectricOther

Rental / Landlord Information (click to expand)
Are you renting?*

YesNo
If applicant is a renter, please provide the landlord's contact information. If applicant is not a renter, proceed to the next section.
Landlord Name

First NameLast Name
Landlord Address

Street Address

Street Address Line 2

CityState

Zip Code
Landlord Phone
Please enter a valid phone number.

Conflict of Interest Attestation (click to expand)
Does the applicant or landlord have any family and/or business ties to Western Dairyland EOC board members or staff?*

YesNo
If yes, please explain:

Signature (click to expand)
I certify that the information on this application and any documents given in connection with it are true to the best of my knowledge. I have read and understand the statements on this application and agree to participate in the Western Dairyland EOC Weatherization Program.
Applicant Signature

Clear
Should be Empty: