Home Security Rebate Program
Jan 03, 2018
submission
#56
Application Form
Applicant Information
| Name | --- |
| Home address (City, State, Zip Code) | --- |
| Best phone number | --- |
| Type of phone | --- |
| Email address | --- |
Demographic Information
| Applicant status | Property Owner |
| Applicant age | 65 years old or over |
| Highest educational level | High school degree or equivalent |
| Household size | 2 persons |
| Household income | Less than $50,000 |
Tell Us About Your Purchase
| What did you buy? | Security camera, Security software app, Door / window lock, Motion-sensor light / timer, Other (please enter description below) |
| Other product | --- |
We Need Your John (or Jane) Hancock!
| I agree to the above statement and affirm the validity of everything I have entered in this application. | --- |