Asterisks (*) indicate required fields.
CUSTOMER INFORMATION
Account Number
*
Owner Name
*
First
Last
Are you the Canby Utility account holder?
*
Yes
No
Relationship to Canby Utility Customer (if not account holder)
*
Family Member
Landlord
Tenant
Phone
*
Email
*
Enter Email
Confirm Email
Site Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Do you have a different mailing address?
*
My mailing address is the same as above
I have a different mailing address
Mailing Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Does the home owner give permission for usage information?
*
Yes
No
HOME INFORMATION
Electric Heat Source
*
Baseboard
Wall
Heat Pump/DHP
Forced Air Electric
Ceiling Cable
Other
Residence must have permanently installed electric heat system capable of heating entire dwelling to qualify.
Other Heat Source
*
Residence Type
*
Site Built Home (up to 4-plex)
Multi-Family (5 or more units, 3 stories or less)
Manufactured Home
Condo/Townhouse
Number of Levels
*
Square Footage
*
Year Built
*
Foundation Type
*
Crawlspace
Slab
Basement
Half-Basement
Existing Windows
*
Existing windows must be single pane, single pane with storms, or double pane with metal frames to qualify. Existing vinyl and double pane wood frame windows
do not qualify
for rebate(s).
Single Pane
Double Pane
Storm
Metal
Wood
Vinyl
Existing Door
*
Insulated
Un-insulated
CONTACT FOR APPOINTMENT
Choose one:
*
Owner
Renter
Owner Name
*
First
Last
Owner Phone
*
Renter Name
*
First
Last
Renter Phone
*
Response/Action
*
Please choose at least one.
Customer Has Bids
Low Use
Remodeling
Willing to act
Contractor Referred
Low Income
Newer Home
High Energy Use
Primary Interest
*
Please choose at least one.
Attic
Floor
Walls
Windows
Other
Other Primary Interest
*
Application Notes
Please insert any notes that you would like us to review with your audit request.