APPLICATION ASSISTANCE INITIAL QUESTIONNAIRE Property Type Residential Commercial Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Are you a full time or part time resident? * Full Time Part Time What township do you live in? * Other Southampton Township East Hampton Township Shelter Island Township Other: What is your household annual income? * Under $300,000 $300,000 - $500,000 $500,000 - $1,000,000 $1,000,000+ Are you interested in working with our team of approved system designers and installers to manage your project from application to installation? * Yes No How did you hear about us? * Thank you for your information, we will contact you to facilitate the process for the Septic Incentive Program.Regards,South Fork Septic, Inc.