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Community Comfort Program Application

Name of Person Submitting Application (required)

Street Address: (required)

City, State, Zip: (required)

Home Phone (required)

Work Phone

Cell Phone

Email: (required)

Applicant Information

Name (required)

Number of Children (required)

Ages

Street Address (required)

City, State, Zip (required)

Home Phone (required)

Work Phone

Cell Phone

Are they Employed? (required)
YesNo

Current Employer

Length of Employment

If not currently employed, what is the reason?

Annual Income (required)
$0 - $10,000$10,000 - $20,000$20,000 - $40,000$40,000 - $50,000$50,000 and Above

Personal References

Name

Relationship

Phone Number


Name

Relationship

Phone Number

Residence/Furnace Information

Do you own your own home? (required)
YesNo

Age of Home: (required)

How long have you lived there? (required)

Number of adults who live in the home, including yourself. (required)

Number of children who live in the home. (required)

Please describe any details of furnace performance problems. (required)

Applicant's Need for Assistance

Please describe any circumstances that may demonstrate any unusual or deserving situation that the selection panel should take into consideration. (required)

Please leave this field empty.

Are you or the nominee related to a current or former employee of Carolina Comfort Air? If so, please give their name and the location they worked out of.

By checking the box below I agree that I understand that completing this application does not guarantee that the person I nominate will receive a replacement furnace and no warranties of any kind. (required)
I understand

Today's Date:

Thank You!

Your appointment has been sent! A Service Rep will contact you shortly to confirm your service call.

Have a Comfy day!

Schedule Your Service Appointment










YesNo
*Additional charges may apply for emergency after-hour service.