Power-Up Northwest Illinois Interest Form Geothermal Site Assessment/Cost Estimate By completing this form, you are showing interest in the Power-UP Northwest Illinois Geothermal program and understand you will be contacted by one of the program contractors. First Name Last Name Address Address Address 2 City/Town ZIP/Postal Code Phone Number Email Utility Provider Utility Provider Name Jo-Carroll Energy MidAmerican ComEd Nicor Other… Enter other… Heating fuel source Heating fuel source Jo-Carroll Energy - Electric Jo-Carroll Energy - Natural Gas Natural Gas LP/Propane Fuel Oil Other… Enter other… Do you have a copy of your utility bill? Utility bill Yes No How did you hear about Power-Up NW Illinois Geothermal? Power-Up NW Illinois Co-op Newsletter Email Co-op website Facebook Online search Word of mouth Other… Enter other… Submit Leave this field blank