Block club or Home Owners Assoc. if none street name.
   
   Name
   
   house Number & Street Name
  (example 123 main street)
   
   Phone (example 773-555-1212)
   
   Valid email address (Required)
   
   Do you have a working porch light or fixture?
   YNYesNo
   
   
   If you do not have a fixture or your fixture is not functional stop here. You are ineligible at this time.
   
   
   
   Does your fixture have a bulb?
   YNYesNo
   What type?
   Bulb TypeLEDCFLOther
   Do you agree to allow us to replace your your bulbs and the above information is accurate?
   YNYesNo
   How interested are you in the provided Dusk to Dawn bulbs and the provided energy efficiency materials? (1-5 scale, not interested to very interested)
   scale12345
   Are you interested in participating in other energy efficiency offering such as our income-eligible Home Energy Upgrades or Kits programs?
   YNYesNo