Please print this form, complete and return this with your payment or mail to:
Green Mountain Power, Attn.: Call Center, P.O. Box 486, Montpelier, VT 05602-0486

Remember, GMP can not guarantee to have power available all of the time. If your life depends on an uninterrupted source of electricity, it is critical for you to have alternate sources available. You should also have a back-up plan in case GMP is not able to restore power quickly.

Name of person using equipment ______________________________

Street Address ___________________________________________

City _____________________________ Phone #______________

GMP Account # __________________________

Emergency contact _____________________ Phone #_____________

Type of life support system ___________________________________

How often do you use the system? _____________________________

Is there an alternate power source available? Yes ____ No ____

If yes, please describe _______________________________________