Weatherization Application

Name		First	Last
Address
Town		Addison Albany Alburg Andover Arlington Athens Bakersfield Baltimore Barnard Barnet Barre City Barre Town Barton Belvidere Bennington Benson Berkshire Berlin Bethel Bloomfield Bolton Bradford Braintree Brandon Brattleboro Bridgewater Bridport Brighton Bristol Brookfield Brookline Brownington Brunswick Burke Burlington Cabot Charlotte Calais Cambridge Canaan Castleton Cavendish Charleston Chelsea Chester Chittenden Clarendon Colchester Concord Corinth Cornwall Coventry Craftsbury Danville Derby Dorset Dover Dummerston Duxbury East Burke East Haven East Montpelier Eden Elmore Enosburg Town Enosburg Village Essex Fair Haven Fairfax Fairfield Fairlee Fayston Ferrisburgh Fletcher Franklin Georgia Glover Goshen Grafton Granby Grand Isle Granville Greensboro Groton Guildhall Guilford Halifax Hancock Hardwick Hartford Hartland Highgate Hinesburg Holland Hubbardton Huntington Hyde Park Irasburg Ira Isle La Motte Jamica Jay Jerico Johnson Kirby Landgrove Leicester Lemington Lincoln Londonderry Lowell Ludlow Lyndonville Lunenberg Maidstone Manchester Marlboro Marshfield Mendon Middlebury Middlesex Middletown Springs Milton Monkton Montgomery Montpelier Moretown Morgan Morristown New Haven Newark Newbury Newfane Newport Center Newport North Hero Northfield Norton Norwich Orange Orleans Orwell Panton Pawlet Peacham Peru Pittsfield Pittsford Plainfield Plymouth Pomfret Pownal Poultney Proctor Putney Randolph Reading Readsboro Richford Town Richford Village Richmond Ripton Rochester Rockingham Roxbury Royalton Rupert Rutland Ryegate Salisbury Sandgate Searsburg Shaftsbury Sharon Sheffield Shelburne Sheldon Shoreham Shrewsbury So Burlington South Hero Springfield St Albans City St Albans Town St Johnsbury Stamford Stannard Starksboro Stockbridge Stowe Strafford Stratton Sudbury Sunderland Sutton Swanton Thetford Tinmouth Topsham Townshend Troy Tunbridge Underhill Vergennes Vernon Vershire Victory Waitsfield Walden Wallingford Waltham Wardsboro Warren Washington Waterbury Waterford Weathersfield Wells West Charleston West Fairlee West Rutland West Windsor Westfield Westford Westminster Westmore Weston Weybridge Wheelock Whitingham Whiting Williamstown Williston Wilmington Windham Windsor Winhall Winooski Wolcott Woodbury Woodford Woodstock Worcester	State Zip
Telephone Number			Message #
E-Mail Address

Dwelling Type= House Apartment Building Trailer Other	Own	Rent
Is the place for sale	Yes	No
How many people live in the dwelling?	Adults	Children
Is anyone in the household over 60?	Yes	No
Is anyone in the household handicapped?	Yes	No
Have you received weatherization before?	Yes	No
Has the house ever received weatherization before?	Yes	No
Are there any plug holes in the exterior walls	Yes	No
Heating Source     Wood Gas Oil Electric Solar Other
Type of water heater      Gas Oil Electric Propane Solar Other

INCOME SOURCES
Wages, Salary, Tips
Self Employment
Unemployment
Disability
ANFC
SSI
SSD
Other

Service Suppliers
Fuel Dealer
Electric Company