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Online Intake Form
1. Personal Information
Please fill out this form to the best of your ability. If you are unsure of how to answer questions on any page, choose the 'Not Sure' option.
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1
. Please enter your name.
Please enter your name.
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2
. Please enter your address.
Please enter your address.
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3
. Please enter the best telephone number at which you can be reached. (Eg. XXX-XXX-XXXX)
Please enter the best telephone number at which you can be reached. (Eg. XXX-XXX-XXXX)
4
. Please enter your email address.
Please enter your email address.
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5
. Where did you first see or hear about us?
Town-Sponsored Event
LIGH Literature
LI Green Homes Employee
Town of Babylon Employee
LIGreenHomes.com
Power Up Communities - LIPC
Newspaper Article
Lawn Sign
Word of Mouth
Private Contractor
Other (please specify)
Where did you first see or hear about us?
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6
. If you had to choose one, which of the following actually convinced you to participate in the program?
Power Up Communities - LIPC
LIGH Literature
LI Green Homes Employee (from presentation)
LI Green Homes Employee (from information booth)
LI Green Homes Employee (from hotline)
Town of Babylon Employee
LIGreenHomes.com
Newspaper Article
Word of Mouth
Private Contractor
If you had to choose one, which of the following actually convinced you to participate in the program?
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