WOW HEAR Program Client Intake Data Form

WOW HEAR Program Client Intake Data Form

Complete this pre-screening to share your contact, service location, energy needs, and eligibility information—submission doesn’t guarantee eligibility or funding. www.wowhear.com
Note: If you encounter difficulty completing this form send email with contact information to efitzgerald@wowtricities.com
Type of Application
Home, Small business, Adult Family Home
Applicant and Contact Information
Legal Name Only

First Name
Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Best Time to Contact
Preferred Language

Other
If Other, please specify language
Do you need an interpreter or other communication accommodation?
Upload Applicant Identification

Cancelof
Service Address and Location
Street Address-Service address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of County ? ( Benton, Franklin, Yakima, Lincoln etc. )
General Information
Is this your primary residence?
Do you own or rent/lease this location?

Other
Business Information
Legal Business Name
Does the business have fewer than 50 total employees?
Businesses must have fewer than 50 employees to meet this program’s small-business pre-screening requirement.
Primary Business Activity / Industry
Is the business actively operating?
Is the business home-based?
Household members
Qualifying public assistance programs

Other
Current primary heating system
Current water-heating system
Current cooking equipment
Does the property have central air conditioning?
Are there any electrical, heating, cooling, hot-water, ventilation, mold, roof, structural, or safety concerns that may affect installation?
Requested Services and Property Access
Improvements of interest

Other
Are you currently working with another agency on this request?
May WOW or an authorized program partner contact you to schedule an assessment?
How did you hear about the WOW HEAR Program?

Other
Consent, Authorization, and Certification
I understand that submitting this intake form does not guarantee eligibility, funding, equipment, or services.
I authorize WOW and authorized HEAR Program partners to contact me, review submitted documents, and verify information needed to determine program eligibility and coordinate services.
I authorize WOW to share only the information reasonably necessary with program administrators, utilities, assessors, contractors, and funding partners for eligibility determination, installation coordination, photos and documentation of work for quality assurance, reporting, and required audits.
Applicant Electronic Signature
Printed Name

First NameMiddle NameLast Name
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

WOW HEAR Program Client Intake Data Form

Note: If you encounter difficulty completing this form send email with contact information to efitzgerald@wowtricities.com

Type of Application

Applicant and Contact Information

Service Address and Location

General Information

Business Information

Requested Services and Property Access

Consent, Authorization, and Certification