AC APPLICATION FORM (2021)
Please fill out the form to qualify
Sign in to Google to save your progress. Learn more
Your Name *
Your Address *
How old are you? *
Which one best describes you? *
Do you have a pre-existing condition that is aggravated by heat? Please provide details *
Does your home or facility allow the installation of an AC unit? *
Can your window accommodate an AC unit installation?
Clear selection
What is the best phone number to reach you? *
Is there a relative that we can contact to assist with the installation? (Please provide name, relationship and phone number)
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.