Pre-Audit Form Name * Required First Last Address * Required Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone * RequiredEmail * Required What are your goals with this Energy Audit? * RequiredApprox. Year of Construction * Required Age of Roof Summary and Age of Additions Architectural Style of Home If Known: Insulation Type in Walls, Attic, Basement Number of Separate Apartments in Building Number of Occupants Number of Bedrooms If Known: Square feet above grade Is the basement heated?YesNoPlease list cold or hot spots in the building and specific issues we need to address: * Required Do you have Carbon Monoxide detectors?YesNoLaundry DryerElectricNatural GasPropaneN/AWhat fuel does it use?Kitchen Cook-topElectricNatural GasPropaneWhat fuel does it use?Kitchen OvenElectricNatural GasPropaneWhat fuel does it use?Do you use a Dehumidifier? If so, how many hours a day? How many days a year?Do you use an Air-Conditioner? If so, how many hours a day? How many days a year?Age of Refrigerator in yearsLeave blank if unknown or not applicable.Age of Freezer in yearsLeave blank if unknown or not applicable.Age of Air Conditioner in yearsLeave blank if unknown or not applicable.HiddenWhich electric utility do you have? Do you have any high use electrical equipment? If so, what?What fuel does your Hot Water Heater use?OilElectricNatural GasPropaneWoodSolarHot Water Heater typeStand Alone TankBoiler Sidearm TankOtherPrimary Heating FuelOilElectricityPropaneNatural GasWoodWhat fuel does your home's primary heat source come from?Primary Heating Fuel Cost For example, $1,350 in oil last winterPrimary Heat DistributionForced Hot AirRadiant FloorHot Water BaseboardConvection/ Space HeaterHow is heat dispersed around your home?Primary Heating Fuel Delivery Schedule(s) You can contact your fuel provider or dealer to obtain this information and attach separate sheets if necessary. Please share 2 years of delivery records showing units (e.g., gallons) delivered and their related delivery dates. For example, 250 gallons delivered on 11/11/2019, 288 gallons delivered on 1/11/2020, etc.Primary Heating Fuel Records Drop files here or Select files Max. file size: 350 MB. Attach files related to your fuel delivery schedule. Secondary Heating FuelOilElectricityPropaneNatural GasWoodWhat fuel does your home's primary heat source come from?Secondary Heating Fuel Cost For example, $230 a cordSecondary Heat DistributionForced Hot AirRadiant FloorHot Water BaseboardConvection/ Space HeaterHow is heat dispersed around your home?Secondary Heating Fuel Delivery Schedule(s) You can contact your fuel provider or dealer to obtain this information and attach separate sheets if necessary. Please share 2 years of delivery records showing units (e.g., gallons) delivered and their related delivery dates. For example, 250 gallons delivered on 11/11/2019, 288 gallons delivered on 1/11/2020, etc.Secondary Heating Fuel Records Drop files here or Select files Max. file size: 350 MB. Attach files related to your fuel delivery schedule. Electric Utility Provider Name on Account Please provide information about your electrical usage for the last 12 months: * Required If unknown or only partially known (e.g., new homeowner), please enter any information you may have related to electrical usage, or enter "not known."Please upload the most recent copy of your electric bill Drop files here or Select files Max. file size: 350 MB. Additional Information Please use this space to detail any other relevant information.Additional Files or Uploads Drop files here or Select files Max. file size: 350 MB. Please use this space to upload any other relevant information.HiddenAccount Number VT Residents: We will access your electrical use through Efficiency Vermont.