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2018-11-22T04:29:14-05:00
Your Name
*
Home Number
*
Business Number
Your Email
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Type of Fuel for Heat
Number of Heating Systems
Do you have a well pump?
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Yes
No
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120 Volts
240 Volts
Don't Know
Do you have a sump pump?
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Yes
No
Do you have a home office?
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Yes
No
In an outage, for how long would you need backup power?
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Yes
No
Number of people living in the home including children?
Do you have a media room?
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Yes
No
Address
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