Greens Gives Back

Nominator Information *

Person Making The Nomination

First Name

Last Name

Phone *

(###)

###

####

Nominee Information *

Individual or Family Being Nominated Greens Heating and Air Conditioning cares about privacy and is committed to protecting personal information in accordance to applicable privacy laws and its privacy policy found at the top of this page. Pursuant to the Greens Gives Back Program Nominee Terms and Conditions, you may only provide information in relation to a nominee if you have received permission from the nominee to provide his/her information to Greens Heating and Air Conditioning. Accordingly, when responding to the below Nomination Form, please limit disclosure of sensitive personal information like financial information, race/ethnicity/sexual orientation, health data and/or private or personal matters concerning any person, including the nominee.

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does nominee/family own this home? *

Yes

No

Unknown

Consent *

I, the undersigned, confirm that all information provided is accurate to the best of my knowledge. I give Greens Heating & Air Conditioning permission to contact me for additional information if needed. I also consent to the use of the nominee's story, name, and photos/videos for promotional purposes, should they be selected.

Yes

No

*

I have received permission to share the above information regarding the nominee.

I have reviewed and agree to program terms and conditions.

I have reviewed and agree to nominator terms and conditions.