KERN CASA Interest Form

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Please read the following carefully

THIS IS AN INTAKE FORM. We are collecting some base information from you through this form. Once submitted we will recieve your information and be reaching out to you via phone and email within 7 business days.

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Please enter your first and last name* This field is required.

First Name

Last Name

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Please enter your phone number* This field is required.

We use this to communicate program updates via call or text.

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Please enter your email address* This field is required.The EV Equity Program and its staff primarily communicate via email. Please provide a valid email address that you have access to.

We will never send you spam or unnecessary emails. We do not share your info with other services

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Please enter your address* This field is required.

Street Address

City

State

Zip Code

Country

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What county do you live in?* This field is required.

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Do you or anyone in your household have a respiratory illness?

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Are you a homeowner?

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How old is your roof?* This field is required.IF UNKNOWN, PLEASE ENTER 0 (ZERO) AND ADD A COMMENT IN THE NOTES AT THE END

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How old is your home?* This field is required.IF UNKNOWN, PLEASE ENTER 0 (ZERO) AND ADD A COMMENT IN THE NOTES AT THE END

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Please select the number of people living in your household* This field is required.This is based off your household listed on your taxes and anyone that is a dependent or you are financially responsible for.

1

2

3

4

5

6

7

8 or more

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