Please check all that apply
a.) If available, I would use natural gas for Home Heating Water Heating Other
b.) Right now I use the following
Oil - Total # gallons used per year
Propane - Total # gallons used per year
Electricity - Total # Kwh used per year
Wood - Total # cords used per year
Other Total # used per year
c.) Square footage of my home
d.) Number of occupants
e.) Name
Address
City
Zip
Email
Daytime Phone	Best time to call
Home Phone	Best time to call