Elizabethtown Gas Weatherization Program

Customer Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone (Primary) *

Phone (Secondary)

What is the best time to call?

List name of spouse or other individual we can speak with

Eligibility Information

Gross monthly income (all household residents ages 18+)

Number of persons (residing in the household)

Elizabethtown Gas Account Number (if not on-hand, we will contact you)

Is your gas service currently active? *

Yes
No

Type of dwelling: *

Single family
Townhouse/condo
Multi-family

Own
Rent (Landlord consent will be necessary)

Authorized Signature

I certify that all information provided above is correct to the best of my knowledge. I give Elizabethtown Gas and Green life Energy Solutions permission to: 1 I share information regarding my home and energy usage with all parties planning to do work on my home or evaluate my energy usage; 2) use, at no charge, any description or pictures relating to the work performed at my home; and 3) have reasonable access to my home to inspect the work performed.

Customer Signature *

Date *