Please complete the following form to book a home energy assessment.   Please note that:

• We need access to all parts of your house, including the attic and furnace.  If access is not available and if the advisor needs to return to complete the evaluation, extra travel costs may apply.
• Evaluations can be completed on row houses, duplexes, and multi-plexes only if there is an exterior door into an entrance or hallway that provides access to all units.
• You must sign a release form allowing us to provide a copy of the results of your home energy assessment to Natural Resources Canada.

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Selected Territory: Smiths Falls, Lanark, Leeds * indicates a mandatory field Scheduling Information
Evaluations are primarily scheduled during weekdays and last 2 to 3 hours.  Please choose from the following:
Preferred visit day:*	SELECT: Monday Tuesday Wednesday Thursday Friday	I would like to request a weekend visit
Preferred visit time:*	SELECT: Morning Afternoon	I would like to request an evening visit
Personal Information
Title:	SELECT: Mr. Ms Miss Mrs.
Full Name:*
Address:*
City:*		Province:*	SELECT: Alberta British Columbia Manitoba New Brunswick Newfoundland N.W.T. Nova Scotia Nunavut Ontario P.E.I. Québec Saskatchewan Yukon
Postal code:*
Email Address:*		Home Phone:*
Work Phone:	Ext.	Cell Phone
Call Preference:	It is best to call me   SELECT: between 9 am and noon between noon and 5 pm between 5 pm and 9 pm any time at my   SELECT: home number work number cell number
Home Information
Style of House:	SELECT: Semi-Detached Single Row House	Age of House:	SELECT: Less than 5 years old 6-10 years old 11-20 years old 21-30 years old 31-50 years old 51-99 years old Older than 100 years
Number of Stories:		Number of Occupants:
Type of Heating Fuel:	SELECT: Gas Electric Wood Oil Combination Other	Type of Water Heating:	SELECT: Gas Electric Oil Other
Do you have a fireplace or woodstove?		Yes    No
What is your primary home comfort problem?
	SELECT: House is too humid (may include mold & mildew problems) House is too dry House is drafty House is cold Heat flow is uneven Cold rooms Other
What is your primary reason for the home energy assessment?
	SELECT: saving money on energy bills having a more comfortable home indoor ventilation concerns getting advice on home renovations accessing government grants other
Pricing Information The price of the assessment varies depending on the location of your home.  The price will be confirmed with you before your visit is booked. Miscellaneous Information
Where did you hear about the service?		SELECT: Utility Company Municipality At Work Newspaper Article Other Media (e.g., radio, TV) Neighbour Friend Colleague Internet NRCAN Contractor RONA Other
Do you know someone else who would benefit from this service? If so, please provide the following contact information. Thank you.
Name:
Address:
Phone number:
Email address:
Do you have any additional questions, information or comments?
Please enter the code shown above:

 

Green Communities Home Energy Solutions is a service provided in Ontario by Green Communities Canada and its member organizations servicing Barrie, Cobourg, Collingwood, Durham, Elora, Guelph, Halton, Hamilton, Kingston, Lanark, Muskoka, Niagara, Parry Sound, Peel, Peterborough, Smiths Falls, Temiskaming, Thunder Bay, Toronto, Waterloo, York.

Green Communities Canada is a national network of community-based non-profit organizations that deliver innovative environmental programs and services with a focus on household and community action.

For more information on Green Communities visit www.greencommunitiescanada.org.

©2009, 2010 Green Communities Canada. All rights reserved.

Green Communities
Home Energy Solutions

P.O. Box 928
Peterborough, ON
CANADA K9J 7A5

Book assessment: 1-888-661-0000
General inquiries: (705) 745-7479
Fax: (705) 745-7294
Email:

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ecoENERGY initiatives help Canadians use energy more efficiently, boost renewable energy supplies and develop cleaner-energy technologies.