Energy Efficiency Program Sign Up

Contact Information

Sign up here for more information on Co-op Power's Massachusetts Energy Efficiency Services. We're a community-owned energy cooperative that helps you reduce your energy use and replace your fossil fuel use with renewables. Co-op Power is a licensed Home Performance Contractor with the Mass Save Program, so we provide no-cost energy assessments, free air sealing, deeply discounted insulation, and other energy efficiency services to those who qualify. Our services are available to the general public with special benefits for our members.

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* 1. Please provide the following information.

Name:

Name as it appears on electric bill:

Name as it appears on natural gas bill.

Address:

City/Town:

State:

Zip:

Day Phone Number:

Evening Phone Number:

Email Address:

Electric Provider:

Electric Account # :

Natural Gas Provider (if you use natural gas):

Natural Gas Account # :

Primary Heating Fuel:

Heat Distribution: Forced Hot Water, Forced Hot Air, Steam, Radiant

Primary Domestic Hot Water (DHW) fuel type?

When was your house built?

What style is your house?

Do you rent or own?

Do you qualify for fuel assistance (so we know if you might be eligible for more free services)?

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* 2. Do you receive a reduced electric rate?

Yes

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* 3. How do you prefer to be contacted?

day phone

evening phone

text

other

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* 4. Do you live in a ....

single family home?

In a building with 2-4 apartments?

In a building with 5 or more apartments?

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* 5. Would you like to join Co-op Power's monthly newsletter? Topics include local energy events, social justice issues, local ownership, savings opportunities, and new renewable energy technologies.

yes

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* 6. How did you hear about Co-op Power's energy efficiency service?

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* 7. When one of our Energy Coaches contact you to schedule your energy assessment, are you interested in learning more about any of our other products and services? Check all that apply.

I am interested in......

A solar electric system (PV)

A solar hot water system

A solar air heater

An on-demand hot water heater

A heat pump hot water heater

A mini split heat pump system

Propane, heating oil and biodiesel purchasing groups

None of the above

comment:

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* 8. Do you have any particular concerns regarding your home that you would like our auditors to know about? (Examples: High utility bills, cold/hot spots, appliances, insulation quality, HVAC systems.)

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* 9. We typically schedule appointments at 9am and 1pm every weekday.
What days and times work best for you?

	Monday	Tuesday	Wednesday	Thursday	Friday
9:00 am	9:00 am Monday	9:00 am Tuesday	9:00 am Wednesday	9:00 am Thursday	9:00 am Friday
1:00 pm	1:00 pm Monday	1:00 pm Tuesday	1:00 pm Wednesday	1:00 pm Thursday	1:00 pm Friday

Other (please specify)

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* 1. Please provide the following information.

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* 2. Do you receive a reduced electric rate?

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* 3. How do you prefer to be contacted?

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* 4. Do you live in a ....

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* 5. Would you like to join Co-op Power's monthly newsletter? Topics include local energy events, social justice issues, local ownership, savings opportunities, and new renewable energy technologies.

Question Title

* 6. How did you hear about Co-op Power's energy efficiency service?

Question Title

* 7. When one of our Energy Coaches contact you to schedule your energy assessment, are you interested in learning more about any of our other products and services? Check all that apply. I am interested in......

Question Title

* 8. Do you have any particular concerns regarding your home that you would like our auditors to know about? (Examples: High utility bills, cold/hot spots, appliances, insulation quality, HVAC systems.)

Question Title

* 9. We typically schedule appointments at 9am and 1pm every weekday. What days and times work best for you?

* 7. When one of our Energy Coaches contact you to schedule your energy assessment, are you interested in learning more about any of our other products and services? Check all that apply.

I am interested in......

* 9. We typically schedule appointments at 9am and 1pm every weekday.
What days and times work best for you?