Energy Savings Program

Home Energy Assessment Interest Form
PARA ESPAÑOL PRECIONE LA BANDERA DE LA PARTE SUPERIOR DERECHA Y ESCOGER IDIOMA
First Name and Last Name*
Address*

Street Address

CityState

Zip Code
Residential Owner
Home ownerRenterOther
Home owner Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Renter / Alternative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail*
If you do not have one, enter a@a.com
EmailTextPhone
ManufacturedSingle - Family DetachedDuplex, triplex, quadruplexTownhomeOther
How many people live in the household? *
ElectricGasOther
YesNo
Portland General ElectricPacific PowerCascade Natural GasNW Natural GasAvistaOther
If you have NW Natural gas what is your account number?
Name of the contractor who assisted you:
Name of person of who assisted you
YesNoOther
If YES what concerns do you have, please explain
In what year was the home built? *
YesNo
YesNo
YesNo
What is your monthly utility bill?*
YesNo
How many hours a day do you use heating during the winter?*
How many hours a day do you use air conditioning during the summer? *
Do you identify as Hispanic and/or Latino? *
Do you prefer speaking in Spanish or English?*
What is your Gross Annual Household Income? *
How did you hear about our program?
Name of Friend or Relative Name
Do you have any other comments or questions for us?
Should be Empty:

Home Energy Assessment Interest Form