CHOC Energy Pre-Qualification Form

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CHOC Energy Pre-Qualification Form

Please fill out this form to let us know if you qualify for CHOC Energy services. Our team will review responses and be in touch. Thank you!

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* Indicates required question

Name *

Your answer

Phone *

Your answer

Email *

Your answer

Are you the Homeowner or Renter? *

I am a Homeowner

I am a Renter

Other:

Required

How many people live in the home? *

Your answer

Does anyone in the home receive Medical, WIC, Cal Fresh, SSI, ETC? *

Yes

No

Please state your monthly income. *

Your answer

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