Community Services Information Request
Comprehensive Energy Assistance Program (CEAP), CSBG Intensive Case Management
Name
*
First Name
Last Name
E-mail
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Requesting information regarding (Please note that this form is not to be used to check status of a previously submitted application, and should only be used to request information regarding programs within the Community Services Department.)
*
Would you like an application mailed to you?
*
Please Select
Yes
No
Submit
Should be Empty: