First Name *

Last Name *

Phone *

Email *

Address

Street Address *

City *

State *

Postal Code *

Are you a Homeowner? *

Yes

No

Owner’s First Name *

Owner’s Last Name *

Owner’s Phone *

Owner’s Email *

Is this your primary residence? *

Yes

No

What type of home is it? *

Single Family

Mobile Home

Muli Family

Other

How many people live in your household? *

How many of those are 18 or older with income? *

What is your monthly household gross income? *

$

Are you currently enrolled in any of these programs? *

Select an option

Who is your electric utility provider? *

Please specify the name of your electric provider *

Duke Account First Name *

Duke Account Last Name *

Duke Account Number *

Electric account number *

What is your primary heating fuel?

Select an option

Gas Provider *

Select the unit of Measurement of your natural gas bills *

Select an option

Propane Provider *

Heating Oil Provider *

Your Signatures *

Clear