RESIDENTIAL CONTACT FORM

Name:
Address:
City:
State:	choose state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Home Number:
Business Number:
E-mail: * (required)

Number of Heating Systems?
Gas please select 0 1 2 3	Oil please select 0 1 2 3	Heat Pump please select 0 1 2 3

Do you have a well pump?

please select yes no

voltage 120 volts 240 volts don't know

Do you have septic pumps?

please select yes no

Do you have a sump pump?

please select yes no

Number of people living in the home including children?

In an outage, for how long would you need backup power?

please select 3-5 hrs 6-9 hrs 12+ hrs

Do you have a home office?

please select yes no

Do you have a media room?

please select yes no

Which of the following items would you like to have on a back up system?
Telephone	Alarm/Fire	Fish tanks
Computer	Garage Door	Entertainment

What is the best time to contact you?

please select business hours evening either

Would you like to receive a brochure?

please select yes no

Any questions/comments?

Privacy Notice:
The information obtained in this survey is considered confidential and will not be sold or transferred.