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2. 
3. Please complete the information below and submit. Or print and mail this form to: Homestead Energy Services - SurgeBlocker 675 N. Flagler Avenue Homestead, FL 33030
7. Surgeblocker Free Assessment Request
10. First Name
11. Last Name
13. Address1
15. Address2
17. City
18. State
19. Zip
21. Date
22. Time
24. Phone #: Home:
26. Phone #: Cell
28. Email
29. HPS Account (if available)
31. Surgeblocker Program
33. Type of Facility

    1. Residence

    1. Business
35. Is this a gated community?

    1. Yes
    2. No
36. If gated, name of the community:
38. Is the location fenced?

    1. Yes
    2. No
40. Is there a dog in the yard?

    1. Yes
    2. No
42. If this is a business, please give the business name:
44. A representative will contact you
46. Preferred Contact Method

    1. Phone Call?

    1. Cell

    1. Home

    1. Email?
48. Best Time to Call:
50. Any additional information you would like to provide:
52. If there are any questions about SURGEBLOCKER or questions about your electrical system, please email: homesteadenergy@cityofhomestead.com or visit our partner's website at www.cesprotect.com.
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit Submit and Print

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