* First Name:
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* Last Name:
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* Address:
(City, State, ZIP)
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* Daytime Phone:
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() -
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* E-mail Address:
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Account Number:
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(Electric)
(Gas)
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* Operating Company:
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CL&P
UI
CNG
SCG
Yankee Gas
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* Usage Time:
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Year-Round
Seasonal Use Only
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* Residence Type:
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Apartment
Single Family
Condo
Duplex
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* Ownership Status:
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Own
Rent
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Average Monthly Utility Bill:
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(Electric)
(Gas)
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Age of Home:
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(Years) |
Heated Square Footage of Home:
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(Sq Ft) |
Central Air Conditioning:
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Yes
No
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Age of Central Air Conditioning:
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(Years) |
* Primary Heat Type:
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Electric Air
Forced Hot
Hot Water Baseboard
Other
If Other:
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* Do you have an oil, propane or
kerosene heating service contract?:
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Yes
No
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* Primary Fuel Type:
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Electric
Gas
Oil
Propane
Other
If Other:
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* Primary Hot Water Type:
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Electric
Gas
Oil
Propane
Other
If Other:
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To determine if you are eligible for additional services, please check the appropriate box:
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Total Gross Household Income:
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$0-$30,000
$31,000-$50,000
$51,000-$70,000
Over $70,000
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Number individuals living in your home:
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| * How did you hear about HES? |
Bill Insert
Direct Mail
Radio/TV
Word of Mouth
State Clean Tune & Test Program
Other
If Other:
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Have you participated in any in-home utility conservation programs within the past 18 months?
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* Previous Participation:
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Yes
No
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Please Describe
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* Confirmation
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I confirm that the above information is
accurate to the best of my knowledge.
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Enter Pre-Qualification Code:
(if available)
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Please correctly type in the following phrase to verify:
Please type e.n.e.r.g.y. without the periods in the box to the right.
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