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English (US)
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Programa Nuestro Hogar Application
Name
First and Last
Home Address
Please include zipcode
Phone Number
Please enter a valid phone number.
E-mail
example@example.com
Are you a NW Natural customer?
Please Select
Yes
No
Not sure
NW Natural Account Number
*
Do you identify as Hispanic and/or Latino/x?
Please Select
Yes
No
Prefer not to answer
Is your home heated by gas?
Please Select
Yes, my home is heated by a gas furnace
No, I have electric heating
I am not sure
Do you prefer speaking in Spanish or English?
Please Select
Spanish
English
Both (Spanglish)
Other
How many permanent residents live in your household?
What is your Gross Annual Household Income?
Please Select
Less than $25,000
$25,000 - $34,999
$35,000 - $49,999
$50,000 - $74,999
$80,000 - $99,999
$100,000 - $149,999
$150,000 - $199,999
$200,000 or more
Dont Know
Prefer not to answer
How did you hear about our program?
Person of Referal / Comapny of Referal / Freinds Name
Do you have any other comments or questions for us?
Submit
Should be Empty: