AACOG Weatherization Program Pre-Application Form

Please fill out this form to pre-apply for services through AACOG's Housing & Weatherization Program.

Please provide the following contact information:

Date

Name

Street Address

City

State/Province

Zip/Postal Code

Phone

Include area code

E-mail

Handicapped

Yes     No

Family Size

Please complete the following Home Information Survey:

Do you live in a::
wood frame house
brick house
mobile home (trailer)
apartment house

Does your roof leak?
Yes
No

Do your ceilings have large holes or cracks?
Yes
No

Do your ceilings have insulation?
Yes
No

Does your home have a good foundation?
Yes
No

Are there any holes in your floors?
Yes
No

Do your walls have large holes or cracks?
Yes
No

Do your walls have insulation?
Yes
No

How many windows does your home have?
wood     aluminum

Are your windows in good condition?
Yes
No

How many doors to the outside does your home have?

Are your doors in good condition?
Yes
No

What do you use to hear your home in the winter?
space heater    How many?
electric heater How many?
Other - Please specify:

What do you use to cool your house in the summer?
window unit    How many?
central unit   How many?
Other - Please specify:

In your opinion, what do you think your home needs the most?

Date
Name
Street Address
City
State/Province
Zip/Postal Code
Phone	Include area code
E-mail
Handicapped	Yes No
Family Size

Please complete the following Home Information Survey:

Do you live in a::	wood frame house brick house mobile home (trailer) apartment house
Does your roof leak?	Yes No
Do your ceilings have large holes or cracks?	Yes No
Do your ceilings have insulation?	Yes No
Does your home have a good foundation?	Yes No
Are there any holes in your floors?	Yes No
Do your walls have large holes or cracks?	Yes No
Do your walls have insulation?	Yes No
How many windows does your home have?	wood aluminum
Are your windows in good condition?	Yes No
How many doors to the outside does your home have?
Are your doors in good condition?	Yes No
What do you use to hear your home in the winter?	space heater How many? electric heater How many? Other - Please specify:
What do you use to cool your house in the summer?	window unit How many? central unit How many? Other - Please specify:
In your opinion, what do you think your home needs the most?