First Nations Conservation Program / Resident Application / 01-17 Page 1 of 2

RESIDENT APPLICATION - First Nations Conservation Program

Please complete this Resident Application (this “Application”) if you are interested in participating

in the First Nations Conservation Program. If you rent or lease your home, you must also

submit a completed Building Owner / Manager Consent. If you need assistance completing this form, please contact Linda Porter toll free at 1 (844) 349-

8972, or (519) 445-1202 or email lporter@klmtech.ca . Completed forms should be submitted to: By Mail Toll-Free Phone Number 1 (844) 349-8972 First Nations Conservation Program E-mail: fncp@fnesl.ca First Nations Engineering Services Ltd. Fax#: (519) 445-4254 Attn: Linda Porter

PO Box 280 - 1786 Chiefswood Road

Ohsweken ON N0A 1M0

RESIDENT INFORMATION: Year of Home FIRST NATION:

Name: Phone Number / Cell Number:

Street Address: City/Town:

Apt/Unit Number: Email Address:

Postal Code: Main Language(s) Spoken:

3. Residence Information

Residence Type: □Fully detached □Semi-detached □Row house/Townhouse □Duplex/triplex/flat

□ Mobile home □ Multi-unit low-rise (up to 3 storeys) □ Apartment in high-rise (4 or more storeys)

My residence is: □ Owned by me □ Rented (non-Band owned housing) □ Rented (Band-owned housing) If you rent or lease your home, please complete the following section

Landlord Name: Landlord Phone Number:

Landlord Address:

City/Town:

Postal Code: Landlord Representative Name and Phone (if applicable)

Hydro One Account Number:

Account number: Do you pay the electricity bill? □ Yes □ No

You must be the primary or secondary account holder, or you must be a resident of Band-Owned Housing, as confirmed

by your Band

How is your home heated? □ Electric □ Natural gas □Wood □ Other ( specify)_______ □ Unsure

If electric, are they: □ Baseboard heaters □ Plug in heaters □ Electric Furnace □ Heat Pump

If heated with natural gas, your provider is □ Enbridge □ Union □ Other (speci fy) _____

How is your water heated? □ Electric □ Natural gas □ Other (specify)_______ □ Unsure

First Nations Conservation Program / Resident Application / 01-17 Page 2 of 2

RESIDENT APPLICATION - First Nations Conservation Program

By signing and submitting this Application, you confirm your consent to, and agree to comply with and be bound by the following:

All information contained in this Application is complete, true and accurate.

You live in your home full time.

You confirm that your home has not previously received any energy efficient devices or products from the Home Assistance Program or the Aboriginal Conservation Program. Hydro One Networks Inc. reserves the right not to approve your Application for any reason in its sole discretion.

If your application is approved, you authorize Hydro One Networks Inc. and/or its contractors to enter your home and conduct an energy efficiency audit at no cost to you.

Subject to the availability of program funds, energy efficient devices and products may be provided

and/or installed at no cost to you. If you and your home are offered any energy efficient products or

devices, you will be asked to complete a Resident Consent form to receive any such items.

Your information will not be shared except as set out in this Application and/or the Resident Consent form.

Hydro One Networks Inc. and/or the Independent Electricity System Operator (“IESO”) may provide

your information to related programs (including gas utility programs) that may benefit you.

As a Participant in the First Nations Conservation Program you consent to the collection, use and

disclosure of your personal information by Hydro One Networks Inc. and the IESO in connection with

the First Nations Conservation Program including for purposes of reporting, follow-up surveys, studies

and audits, and the provision to the IESO of your past and current energy usage for such purposes (as well

as disclosure to the Ontario Energy Board, the Ontario Ministry of Energy and/or the Ontario

Environmental Commissioner or their respective successors.) You understand that in connection with

surveys, studies and audits, the IESO may contact you directly, including by email and other electronic

communication. You may withdraw this consent at any time by contacting Hydro One Networks Inc. or

the IESO. You may contact Hydro One Networks Inc. at privacy@hydroone.com or 1-888-664-9376,

and the IESO at privacy@ieso.ca or 416-969-6277 to access copies of their respective privacy policies

should you wish to review them.

Neither of the IESO nor Hydro One Networks Inc. nor any of their respective officers, directors,

employees, affiliates or contractors and such affiliates’ respective officers, directors or employees

(collectively “Representatives”) will be liable for any injury, damage or loss to persons or property arising

from or related to the audit, installation or the use of energy efficient products or devices, whether in

accordance with the manufacturer’s instructions or otherwise, or from any actions, omissions, negligence

or misconduct by Hydro One Networks Inc., or IESO or their respective Representatives, and you hereby

release the IESO, Hydro One Networks Inc. and their respective Representatives of, from and against any

and all of the foregoing.

Except as specifically set forth or referenced in this Application, there are no representations, warranties,

or conditions of Hydro One Networks Inc. or the IESO, express, implied, statutory or otherwise, regarding

any matter, including any implied warranties or conditions of quality, workmanship, safety, legal

compliance or fitness for a particular purpose. Without limiting the generality of the foregoing, you

acknowledge that your participation in the First Nations Conservation Program is based upon your own

assessment of First Nations Conservation Program and not on any reliance on anticipated or projected

results, and that such participation may not result in the achievement of any electricity savings or demand

savings.

NAME: (Please print)

SIGNATURE:

DATE:

Official Use Only - File #: