Name of Person Submitting Application (required)
Street Address: (required)
City, State, Zip: (required)
Home Phone (required)
Number of Children (required)
Street Address (required)
City, State, Zip (required)
Are they Employed? (required)
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
Do you own your own home? (required)
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)
Please describe briefly the financial situation and need of the family. (required)
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)
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