Form

Home Run For Home Comfort!
Name*
Address*
City*
Zip code*
Phone Number*
E-mail*
How did you hear about the "Home Run For Home Comfort" giveaway?*

66ers Stadium Facebook Our Website Internet Search Newspaper Word of Mouth JBS Service Technician Friend
Are you nominating a deserving person who is in need of an air conditioning system? If so, what is their name:*
Relationship to the nominated person:*

Self Relative Friend Peer Neighbor Anonymous JBS Service Technician Other
Address
City
Zip Code
Phone Number
Do you know their e-mail address?
Is this property owned or a rental?*
Is the home Single Story or 2-Story?*
Does the home currently have a Home Comfort System installed?*

Yes No
Are there children under the age of 18 in the home?

Yes No
Does anyone in the household suffer from any of the following:

Asthma Respiratory Problems Dry/Itchy Eyes Headaches Disease Cancer Other
Is there duct work currently installed in the home?*

Yes No Don't Know
How old is the home?
Submit a photo if you would like!
Wondering what qualifies a family as deserving? We know that many families have had a difficult past few months, or maybe years, due to the economy and they may have not been able to afford a new Home Comfort System. Maybe you know (or are) a family whose been through recent personal hardships. Or you might know someone who is always giving back to others but never has a chance to treat themselves. Any of these and many other situations would qualify a family as deserving of this unique gift. Make sure to enter the deserving family (yes, it is ok to nominate your own family if you choose!) by August 22nd, 2011 to be eligible. So tell us their story in 500 words or less!*
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Home Run For Home Comfort!