testing pdf 2

Full Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Is your mailing address the same as where you live?*

Address

Street Address Address Line 2 City State ZIP Code

Resource Questionnaire

What type of electric assistive technology or durable medical equipment do you use?*

Example: Power wheelchair, CPAP Machine, Speech Tablet

How many hours a day do you use each of the devices you listed above?*

Example: Power wheelchair-4 hours, CPAP Machine-8 hours, Speech Tablet-5 hours.

Select a Living Arrangement*

If power were to go out at your home, do you have any backup source of electricity to use?*

Are you on a Medical Baseline Program for either PG&E or SCE?*

Do you have a personal or household emergency plan?*

Are you receiving or are you eligible for any type of public benefits?*

What type of PSPS assistance do you need?*

Provide a short description of what you're requiring

What is the best time of day to reach you to discuss and review your application?*

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