Application Form
SMALL BUSINESS & NONPROFIT ENERGY ASSISTANCE PROGRAM
Customer Information
Customer Account #:
Customer Name:
Customer Billing Address:
Address:
Address Line 2:
City:
State: Zip:
Contact Person:
First Name:
Last Name:
Contact Phone:
Email Address:
Re-Enter Your Email Address:
Type of Organization
Charitable nonprofit organization (mission-driven 501(c)3 corporation)
Community center - Senior center or Adult day-care services
Cooling center
Faith-based organization
Homeless services center
Learning institutions
People with disabilities or supportive living center
Youth or Day care centers
Small Business Customer, defined as
An independently owned and operated business with its principal office in Illinois
Gross Sales less than $4 million or has 50
or
fewer full time employees
Other (please describe)
Hardship
I have read and agree to the terms and conditions of the
Information Request and Consent Form
.