Power Outage Emergency Kit Checklist Form

Full Name

First NameLast Name

Primary Contact Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Number of People in Household

Type of Residence

Do you currently have a Power Outage Emergency Kit prepared?

When was your emergency kit last checked or updated?

Which items do you have in your Emergency Kit? (Select all that apply)

Do you have any pets or household members with special needs?

Additional Comments or Notes