EECN - Energy Efficiency Community Network

National Rental Insulation Programme – Application Form

Please note: EECN will assess your application and pass your contact details onto one of our member trusts in your area.

Name

Street Address

Suburb

Telephone (home)

Telephone (mobile)

Email address

Tick

Are you a landlord wanting to insulate a rental property?

Are you a tenant wanting to insulate the property you rent?

TENANTS:

If you rent please provide the contact details of the owner (landlord).
Please note: we will not contact your landlord until we have made contact with you.

Landlord’s Name

Landlord’s Address

Landlord’s Telephone

LANDLORDS:
If you own a rental property please provide the contact details of the tenant.
Please note: we will not contact the tenant until we have made contact with you.

Tenant's Name

Address of Rental Property

Tenant's Telephone

Do you hold (or are you eligible for) a Community Services Card (CSC)?

Yes - CSC #

Important:
Do you or your family suffer from any respiratory or other chronic illness that may be alleviated by living in a warmer drier home?

Yes (please specify)

Has your ceiling been insulated in the last 10 years?	Yes	No	Unsure

Has you underfloor been insulated in the last 10 years?	Yes	No	Unsure

Is your ceiling easily accessible?	Yes	No

Is your under-floor easily accessible?	Yes	No

Date when house was constructed:	eg; 1956

How did you hear about the Insulation Projects and/or subsidies?

Any Comments?

Can we contact you about any other EECN initiatives in your area?

Yes

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Energy Efficiency Community Network - Promoting Energy Efficiency in the Community
For more information, contact your local EECN office or EECA on 0800 358676
or email us at info@eecn.org.nz