Energy Assessment and Estimates - Primary Contractor Intake Assistance & Consent Form
Diversified Professional Services Group, Inc.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Michigan Energy Rebates Approval Number (Ex. - EA-0000123456)
*
Have you been approved for Standard Rebates or Enhance Rebates? Please choose one.
*
Please Select
Standard Rebates
Enhanced Rebates
NONE
Have you had an energy assessment completed?
*
Please Select
YES
NO
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Are you a Homeowner or a Renter?
*
Do you currently reside at this address? (Yes/No)
*
Which of the following services are you interested in? (Select all that apply)
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Energy Efficiency Upgrades
Furnace Replacement or Repair
Insulation and Air Sealing
Water Heater Replacement
Windows or Doors
Electrical Panel Upgrade
Electrical Wiring Repairs
Health and Safety concerns
Other
Are you working with another [Primary] Contractor or Assessor? If so, please detail
*
Please Select
YES
NO
If yes, please provide details:
Please tell us about your home, what you are looking for, and how we can help.
*
What is your budget for your improvements?
*
How do you prefer to be contacted?
*
Please Select
Phone
Email
Consent & Authorization
By submitting this form, I authorize Diversified Professional Services Group, Inc., herein referred to as DPSG, Inc., (a licensed, insured, and approved Primary Contractor) and/or its approved associates and community partners to assist me in scheduling my energy assessment/audit for the purposes of utilizing rebates that I have been approved for. I confirm that at the time of completion of this form, I am not working with another Primary Contractor or energy assessor and that I am requesting that DPSG, Inc. would assist me in getting scheduled to have my energy assessment performed and becoming my Primary Contractor who will assist me in completing approved work to my property. I consent to be contacted by DPSG, Inc. and/or its authorized associates and community partners regarding this application to have my energy assessment and related services completed. If approved for energy rebates or other funding, I authorize DPSG, Inc. to facilitate, manage, and/or act as my approved Primary Contractor to assist me in performing approved safety, assessments, audits, weatherization, and rebate repairs that are covered under the qualifying rebates that are available in my area or any other energy, utility, or assistance program(s) that I may be qualified for. I consent to share my information with participating contractors or agencies only for the purpose of facilitating or delivering these services.
*
Yes
Signature or Initials
*
Date
*
-
Month
-
Day
Year
Date
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