Customer Name:

Street Address:

City, State, Zip Code:

Account Number:

Account Name: (if different from above)

Daytime Phone Number:

Evening Phone Number:

E-mail Address:

Please identify any concerns you have regarding your energy usage.

I authorize KU to conduct a home energy survey and provide an energy savings analysis of the residence listed above. I understand that the total cost of this service is $15, payable with this application. (Please do not send cash.) I authorize KU to obtain information on the energy use at the listed residence, from all my energy suppliers, in order to help complete the energy analysis.

  Yes, please apply the $15 audit fee to my KU bill

I understand that the survey is not a safety analysis of my home or its appliances. I further understand that I should have my appliances inspected and serviced regularly, for safety reasons, by experienced professionals such as heating, ventilation and air conditioning (HVAC) contractors.