New Jersey Comfort Partners Program

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?

Gross monthly income (all household residents ages 18+) *

Before taxes are taken out.

Number of persons (residing in the household) *

Including children.

Check if you participate in:

Type of Heating Fuel: *

Name of Electric Company: *

Electric Account Number:

Name of Gas Company: (if applicable) *

Gas Account Number:

Type of dwelling: *

Do you pay directly for your heating? *

If "No" then not eligible.

Do you own your refrigerator? *

Is your utility service currently active? *

Authorized Signature *

I certify that all information provided above is correct to the best of my knowledge, and I give the New Jersey Board of Public Utilities, NJ’s Clean Energy Program and participating New Jersey Comfort Partners utilities and contractors permission to: 1) share my records 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. I understand that all work is guaranteed for a period of one year.

Date *

How did you hear about the program? *