IQ – Weatherization Application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Customer Information household) about on Name *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Phone (Primary) *Phone (Secondary)What is the best time to call?Please Choose8am – 11am11am – 2pm2pm – 5pmEligibility InformationNumber of people (residing in the household) *Please Choose123456789+Including children.Annual IncomeType 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: *15+ Dwelling (not eligible)1 – 14 Unit Dwelling1 – 8 DwellingDo 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 SMS consentI agree to receive customer-care text messages from GreenLife Energy Solutions regarding inquiries, applications, appointments, project updates, document requests, and service follow-up.By checking this box, you agree to receive customer-care text messages from GreenLife Energy Solutions about inquiries, applications, appointments, document requests, project updates, and service follow-up. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for assistance. Consent is not required to receive services. Privacy Policy and Terms: https://greenlifeisgood.com/privacy-policy-and-terms-and-conditions/Submit
