HVACR Education Resource Network
Request For Assistance
info@hx1.net
Phone: 800‐726‐9696
Fax: 800‐546‐3726
Full Name
*
First Name
Last Name
Title:
*
Organization:
*
Organization Type:
*
Please Select
Secondary
Post Secondary
JATC
Charter
Union
Other
If "other" is selected, please specify.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone Number
*
E-mail
*
example@example.com
Cell Phone Number:
Please enter a valid phone number.
Website:
*
Ex: www.Escogroup.org
Is the person listed above the main contact for the HVAC Lab Development?
Please Select
Yes
No
If "no" who is the primary contact?
First Name
Last Name
Title
Email
Phone Number
Please enter a valid phone number.
Is your school/program:
*
Profit
Not-for-Profit
Public
Are you eligible to receive Perkins Funding?
*
Yes
No
Tell Us About Your Program:
Please complete all information requested below. If this is a new program, please answer based on expected information.
Is your HVACR Program? Check all that apply.
*
New
Existing
Full Time
Part Time
Day Program
Night Program
Program Launch Date and Program Hours:
*
Program Launch Date
Program Hours
Present/Expected Student Enrollment:
*
Number of annual graduates:
*
Type of credentials received:
*
certificate/diploma/degree)
Number of full-time faculty members:
*
Number of part-time faculty members:
*
Present or Expected Annual Budget:
*
Square footage of facility devoted to the HVAC/R program:
*
Number or Classrooms/Labs?
*
Classroom
Labs
Square footage of each lab:
*
Type of Assistance Needed:
Submit
Should be Empty: