Home Energy Assessment Form Form to gather Home Energy Assessment information to generate invoice. Date of Test(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name of Job(Required)Home or Business Location nameLocation of Job Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Home InformationNegative Air Pressure(Required)Worst Case Scenario Test (Turn on all exhaust fans, dryer, make up air unit and record the negative pressure.Make Up Air UnitExhaustWater HeaterModelModel of the Water HeaterWater Heater AgeWhen was Heater InstalledGallonsSize of the water heaterPhoto of data plateTake a photo of the data plate on the Water Heater Drop files here or Select files Accepted file types: png, jpg, gif, pdf, jpeg, Max. file size: 50 MB. FurnaceGather information about the FurnaceModelModel of the FurnaceFurnace AgeWhen was Furnace InstalledEnergy Type and usageAdd the energy type, such as KW, Volts/Amps, Therms, BTUs and the amount drawn.Fuel SourceGas, Electric, PropanePhoto of data plateTake a photo of the data plate on the Furnace Drop files here or Select files Accepted file types: png, jpg, gif, pdf, jpeg, Max. file size: 50 MB. Condensing UnitsAir Conditioners, etc.ModelAgeWhen was the unit installedPhoto of data plateTake a photo of the data plate on the Condensing Unit Drop files here or Select files Accepted file types: png, jpg, gif, pdf, jpeg, Max. file size: 50 MB. WindowsAgeWhen were the windows installedPane thicknessSingle or Double pain glass Single Pane Double Pane Frame MaterialWhat is the frame made of, wood, metal, fiberglass?Relevant photosTake photos of the windows and identifying data Drop files here or Select files Accepted file types: png, jpg, gif, pdf, jpeg, Max. file size: 50 MB. Structure informationSquare Footage(Required)Enclosure Volume (Cubic Ft)(Required)CFM @ 50 Pa(Required)ACH @ 50(Required)Thermal ImagesWith Blower Door running, check all the windows, doors, walls, etc. with the thermal imaging camera and save relevant photos Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB. Customer Name(Required) Name of Customer/Business Contact Name(Required) First Last Contact Email Contact PhoneNotes
