NRGwise Appointments

First Name

Last Name

Address

City

Province

Postal Code

Phone

Email Address

Please contact me to schedule: Please contact me to schedule: My initial energy assessment, prior to completing any upgrades. My final energy assessment, after all upgrades are completed.

Are you applying for the $40,000 interest free loan? Are you applying for the $40,000 interest free loan? Yes No

If yes, please provide your loan application # (if available):

Type of House Type of House Detached Semi-Detached Row/Townhouse Mobile Home Other - please fill in text field below

Other:

Number of stories Number of stories 1 2 3

Year built or approximate age

Approximate square feet of house

Number of wood burning appliances * All wood appliances must be cleaned out 24 hours prior to energy assessment appointment

Main Source of Heat in the House Main Source of Heat in the House Gas Electric Other

Planned Upgrades Planned Upgrades Attic Insulation Main Wall Insulation Foundation Insulation Air Source Heat Pump Ground Source Heat Pump Domestic Hot Water Heat Pump Windows or Doors Solar PV Other - Please fill in text field below

Other:

I acknowledge the following statements (please check all) I acknowledge the following statements (please check all) I will provide a copy of their property tax form including roll #, to the energy advisor at the time of the onsite evaluation. I will provide a recent copy of the gas or utility bill to the Energy Advisor at the time of the onsite evaluation. I understand that the Energy Advisor will take photos of the house and mechanical components. I understand that one of the homeowners listed on the Property Tax form must be present during the onsite evaluation. I understand that the Energy Advisor will require access to every room in the house including the attic, basement and crawlspace. I understand that any work initiated prior to the initial energy assessment, will not be eligible for incentives.

By submitting this form, you hereby agree to accept our Terms & Conditions. By submitting this form, you hereby agree to accept our Terms & Conditions. Yes