SELF-ENERGY AUDIT PROGRAMME

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Self Energy Audit Application Form

APPLY TODAY!

CAREEP Self Energy Audits and Lightbulb-Exchange Programme

ConserVE-2-SaVE

Learn how to SAVE energy and REDUCE your monthly Electricity bill and RECEIVE highly efficient LED lightbulbs for FREE!

1. ABOUT THE CARILEC RESILIENCY AND ENERGY EFFICIENCY PROJECT (CAREEP)

CARILEC and your local utility are implementing the CARILEC Resiliency and Energy Efficiency Project (CAREEP), supported by the RESEMBID Programme, implemented by Expertise France on behalf of the EU. The Project specifically targets energy affordability for residential electricity customers. The Project aims to include mainstreaming energy conservation measures and technologies, as well as to build capacities for new and innovative energy services, by diversifying the skills of the local workforce.

2. BENEFITS OF PARTICIPATION:

Learn how to save energy and reduce your monthly electricity bill!
Receive highly efficient LED Lightbulbs and/or Power Monitoring Devices for FREE and reduce your electricity consumption for lighting by up to 10 times!
Be part of a growing community of energy efficient households in your country!
Control your consumption, implement innovative, green, and cost-efficient energy saving measures!
Receive guidance on how you can implement energy efficiency measures in your household and share your experiences with other households in your neighbourhood and country!
Become a community CHAMPION for Energy Efficiency in your neighbourhood!

3. HOW CAN YOU PARTICIPATE AND BENEFIT FROM THIS PROJECT?

You have a customer account with your Utility as a residential customer.
You have access to the internet and an own e-mail account.
Your monthly electricity consumption is below 400 kWh (Anguilla, British Virgin Islands, Sint Maarten, and Montserrat), 600 kWh (Turks and Caicos Islands) and 2,000 kWh (Cayman Islands).
You are currently using standard incandescent lightbulbs or compact fluorescent lightbulbs for your main household lamps (ceiling and floor lights in kitchen, living room area, bedrooms, washrooms, hallways, and veranda).
LED lightbulbs recipients /households will be required to hand-over old lightbulbs for disposal at the assigned country store.
You have successfully registered and have submitted the CAREEP Baseline Survey on Knowledge, Behaviour and Perceptions on Energy Efficiency
CAREEP Implementation Guide for Energy Self-Audits to conduct your self-energy-audit today!
As part of the registration process, you will commit to:

- Follow the instructions for lightbulbs installation and visually document the lightbulb replacement by submitting a photo to the CAREEP project at [email protected]
- Monitor your monthly electricity consumption/usage and submit the data to the CAREEP project at [email protected]
- Agree to sharing of the energy data assessed during the Project and be available for communication with the CAREEP Project representatives and local stakeholders.
- Collect the lightbulbs upon approval from your local LED sales point, and handover the old and inefficient lightbulbs for proper disposal.

Utility*

Country

1. CONTACT INFORMATION:

1. Full Name of Household Contact:*

First Last

2. Customer Account Number*

3. Email of Household Contact:*

4. Mobile of Household Contact:*

5. Address of household:*

Street Address City State / Province / Region

2. HOUSEHOLD COMPOSITION:

6. Gender of household members

Female*

Male*

Other*

7. Age of household members

How many members (Age 20)*

How many members (Between 20-30)*

How many members (Between 30-40)*

How many members (Between 40-50)*

How many members (Between 50-60)*

How many members (Between 60-70)*

How many members (Above 70)*

3. ELECTRICITY INFORMATION

8. What was the amount of electricity consumed according to your last electricity bill?*

4. DECLARATIONS

You are required to sign this form when collecting your LED lightbulbs and dropping off your old bulbs

I (

Last Name

), hereby agree to the following:

Declarations*

I hereby declare that the information provided under this registration form is true and correct.

I agree that the data submitted on this registration form and provided throughout the implementation of the CAREEP activity will be used by the CAREEP Project staff for Project implementation, evaluation, and result publication (anonymously).

I agree to be contacted via email or phone by the CAREEP project team and Name of Utility regarding the implementation of this Project and any further follow-up.

I commit to submit my monthly energy consumption in kWh as per electricity bill to [email protected] for the following 12 months upon receipt and installation of the LED lightbulbs within this activity.

I commit to fill out and submit the questionnaire for the CAREEP ex-post Survey on Knowledge, Behaviour and Perceptions on Energy Efficiency after 12 months upon receipt and installation of the LED lightbulbs within this activity.

I assume full responsibility for all risks arising directly or indirectly from my possession, sue or misuse of the received LED lightbulbs, both known and unknown, regardless of the cause. I waive and release any claims against CARILEC and its CAREEP Project partners with respect to any and all injury, disability, death, loss and damage to property resulting from possession, use or misuse of the LED lightbulbs, regardless of the cause and even if caused by negligence, whether passive or active

Optional Declarations

Optional: I agree to be interviewed and filmed to document best-practices, results, and experiences for further publication within the CAREEP`s public education and awareness-building campaign on Energy Efficiency.

Date*

Please type your full name in capital letters/blocks*