Weatherization Application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Customer InformationName *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Phone (Primary) *Phone (Secondary) of rent Name What is the best time to call?Please Choose8am – 11am11am – 2pm2pm – 5pmEligibility InformationNumber of persons (residing in the household) *Please Choose123456789+Including children.Check if you participate in:HEAPLIFELINEPAADSECTION 8SSITANFUSFSNAPType of Heating Fuel: *Natural GasElectricityOilOther FuelName of Electric Company: *Choose OneAtlantic City ElectricJersey Central Power & LightPublic Service Gas & ElectricOtherWhat is your Electric utility account number? *Name on Electric account: *Name of Gas Company: (if applicable) *Choose OneN/A (All Electric)South Jersey GasNew Jersey Natural GasElizabethtown GasPublic Service Gas & ElectricOtherWhat is your Gas utility account number? *Name on Gas account: *Type of dwelling: *1 – 14 Unit Dwelling15+ Dwelling (not eligible)Do you rent or own? *OwnRent (Landlord consent will be necessary)Do you pay directly for your heating? *YesNoIf “No” then not eligible.How did you hear about GreenLife Energy Solutions? *Choose OneFamily/friendsFacebookPostcardsGas or Electric UtilityLIHEAP or USFAdvertisements about New Jersey Clean Energy ProgramOtherPlease sign below * Clear Signature Submit
