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Full Name
Address
Phone
Email Address
Single Residence?
Yes
Own/Rent
Own
Approx. Monthly Bill?
Unknown
Less Than $150
$150 - $200
$200 - $250
$250 - $300
$300 - $350
$350 - $400
$400 - $450
More Than $450
Electric Provider
Austin Energy
CPS Energy
Center Point Energy
Oncor Energy
TNMP
AEP North and Central
Pedernales Electric
CoServ
Blubonnet Electric
Guadalupe Valley Electric
Tri-country Electric
United Cooperative Services
El Paso Electric
Bartlett Electric
BPUB, Entergy Texas
Sam Houston Electric
Condition of Roof
Unknown
Poor
Ok
Good
Excellent
Type of Roof
Other
Shingle
Metal
Flat Rubber
Tile
Approx. Amount of Shade
Unknown
None
Little
Some
A lot
Are you retired or employed on a fixed income?
Unknown
Retired
Fixed Income
Approx.Credit Score of 640 or Higher
In an HOA?
No
Yes
Combined Gross Household Income of at Least $40,000 Annually?
Yes
Do you own an Electric car now or planning to have one?
No
Yes
Notes/Concerns/Special Requests
Agent
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