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) own? Email Solutions? 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 SMS Privacy Disclaimer *I consent to receiving text messages from GreenLife Energy SolutionsBy submitting this form and signing up for texts, you consent to receive text messages from GreenLife Energy Solutions at the number provided, including messages sent by auto dialer. Consent is not a condition of purchase. Msg & data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP or clicking the unsubscribe link (where available) and no further messages will be sent. Reply HELP for help. View Privacy PolicySubmit
