Weatherization Intake Form
Use this questionnaire if the customer would like to make their home/business more energy efficient.

If no answers to required questions then type "n/a." If the client does not want to proceed the Program Questions [section 2] then type "n/a" in each line item or select "None Known Of."

Questions in [brackets] are instructions for you and not to be relayed to the customer.

First Name *
Your answer
Last Name *
Your answer
Phone *
Your answer
Is this a cell phone, home or business line? *
Email *
Your answer
What is your preferred contact method? [Select all that apply] *
Required
Is this for a residence or commercial property? *
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Were you referred by anyone or any program? [If not given, select "Cold Call"] *
Would you like to list an additional contact? If so, who would you like as your secondary contact? *
Your answer
What is the best number for the secondary contact? *
Your answer
What is the best email address for the secondary contact? *
Your answer
Would you like our team to do the following? *
Required
So we can accomodate your schedule, when would you like us to come out to your residence? Are there better days or times in the day? Someone will call to schedule *
Your answer
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