Applicant Details
Sign Up Form: Energy Affordability and Oil to Heat Pump Affordability Program By Save On Energy
Name
*
First Name
Last Name
Email
example@example.com
Confirm email
Street Address
E.g., 4746 Wellington Street
City
E.g., Toronto
Province
E.g., Ontario
Postal Code
E.g., M9C 3J5
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Does the participant have any accessibility needs or requirements?
Yes (the alternative/ care giver phone number will be contacted by our team)
No
Is your home oil heated?
Yes
No
Qualification Method
Please Select
Guaranteed Income Supplement
Allowance for Seniors
Ontario Works
Ontario Disability Support Program (ODSP)
Healthy Smiles Ontario Child Dental Program
Low-Income Energy Assistance Program (LEAP)
Ontario Electricity Support Program (OESP)
Allowance for the Survivor
Income qualified
By submitting this form, I confirm that the participant has provided consent for their contact information to be collected and used by CLEAResult Canada for the purpose of being contacted about the Energy Affordability Program
*
Yes
Form Notes
Please Select
Outreach - Market Sign Up Leads
Submit
Should be Empty: