First Name/Nombre
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Last Name / Apellido
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Phone / Telefono
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SMS Consent checkbox
I agree to receive text messages from Free Main Panel about my eligibility and appointment. Msg & data rates may apply. Message frequency varies. Reply STOP to opt out, HELP for help.
Email / Correo Electronico
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Are you a Southern California Edison customer? Es usted cliente de Southern California Edison?
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Yes
No
Not Sure
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Does your household receive any of the following state benefits ? (check all that apply )
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Medical (Medi-Cal)
FoodStamps (CalFresh)
WIC
SSI (Supplemental Security Income)
How did your hear about us ? Como escucharon de nosotros?
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Check Eligibility / Cheque Elegibilidad