First Name *
Last Name *
Phone Number *
Email

Pacific Power account number *
Have you received no more than two kits in the past 10 years?
(Only two kits per household every 10 years)*

YesNo

Address 1 *
Address 2
City *
State*
Zip*
Do you have electric water heat?*
YesNo
If you answered “Yes,” how many bathroom showers do you have?

Do you qualify for CARE alternative rates? (California only)*
YesNo
Is the primary language spoken at home other than English?*
YesNo
Are you a tenant/occupant of the location?*
YesNo
What type of home do you live in?*
Single FamilyMultifamilyManufactured
I agree to the terms and conditions*