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First Name

Last Name

Address

City

Zip

State/Province

Email

Phone

Lead Source
CRC

Building Type:
–None– Single-Family Multi-Family Mobile Home Duplex Triplex Fourplex Shelter Other unit category

Occupancy:
–None– Owner Occupied Tenant Occupied

Number of Occupants:

Number of Bedrooms:
–None– 1 2 3 4 5 6 7

Number of Bathrooms:
–None– 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7

Style:
–None– Townhouse (party walls) Stacked Units

Year Built:

Electric Utility:
–None– Xcel Energy LPC (Longmont Power & Communications) PVREA (Poudre Valley Rural Power Assoc) United Power Lyons Power Estes Park No Electric Utility

Electric Utility #:

Gas Utility:
–None– Xcel Energy No Gas Utility Other

Gas Utility #:

HOA Controlled?:
–None– Yes No

Previous Program Participation:
–None– Boulder Green Buildings and Green Points ClimateSmart Loan Program Residential Energy Action Program (REAP) SWEEP by Volunteers Weatherization Program

Primary Customer Participation Reason:
–None– Comfort Energy Cost Savings Environmental Impact SmartRegs

Homeowner Availability: Days of Week (hold control key for multiple selections):
Monday Tuesday Wednesday Thursday Friday

Homeowner Availability: Times of Day (hold control key for multiple selections):
9am-11am 10am-12pm 11am-1pm 12pm-2pm 1pm-3pm 2pm-4pm 3pm-5pm

I have a contractor already:
–None– Yes No

If Yes, Contractor Name:

Audit in the last 3 Years?:
–None– Yes No

What type of service would you like?:
–None– EnergySmart Audit ($120) Xcel Energy Audit ($120) SmartRegs Inspection ($120) Advisor Only (had audit within last 3 years – no cost) Advisor Only ($30)

Homeowner Priority 1:

Homeowner Priority 2:

Homeowner Priority 3:

Comfort Issues?:
…