Name

E-mail Address    Phone Number

Address

City     State      Zip

Construction of home:   Aluminum/Vinyl Siding Asbestos Siding Stone/Brick Log other

Does the home have a  Basement Crawl Space On Slab

Approximate age of home  yrs.

Are your roof shingles light or dark? 

Does the kitchen have an exhaust fan? Yes No  Does the roof have a ridge vent or power attic fan? Yes No

(Note: not a full house fan)

Do the bathrooms have exhaust fans? Yes No   If so, which bathrooms? 

How many heating thermostats are in your house? 

What type of heat do you have now?   Electric Heat Pump Hot Water Steam Warm Air Other

Do you get your domestic hot water for showers, baths and sinks from your present system?  Yes No

Optional Questions:        (These do not need to be answered. They are for informational purposes only)

Manufacturer of heating equipment 

Model # of heating equipment 

Age of equipment (if known)   years

BTU Rating of current heating equipment  Which Rating Input Rating Gross Output Rating DOE Rating Net Output Sq FT Rating (Steam Only)   Amount BTU's   Any comments you would like to add.

Additional Notes:
Double check that all paperwork is filled out properly.   (I have received a few lately missing room sizes.)

Is all the information on the Mailing Information Sheet accurate?

If there are any questions please contact us @ 717-545-4067  or e-mail

Drawings  or Digital pictures will be helpful.