000
ERROR MESSAGE
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USA/CANADA
ZIP/POSTAL CODE
OTHER COUNTRIES
CITY
COUNTRY
Albania
Algeria
American Samoa
Andorra Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Ascension Island
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burma Burundi
Camaroon
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote D Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Federated States of Micronesia
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Gaza Strip
Georgia
Germany
Ghana
Gibralter
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea Bissau
Guyana
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jarvis Island
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Peoples Republic of)
Korea (Republic of)
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Guinea
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Cypress
Northern Mariana Islands
Norway
Not Specified
Oman
Pakistan
Palau
Panama
Papua
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands (U.K.)
Virgin Islands (U.S.)
Wallis and Futuna Islands
West Bank
Western Sahara
Western Samoa
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
CITY OF RESIDENCE
Select
ADULTS IN HOUSEHOLD
1
2
3
4
5
6
I LIVE IN A(N):
SINGLE FAMILY HOME
DUPLEX / CONDO / APARTMENT
ROOM / DORM
NUMBER OF BEDROOMS
1
2
3
4
5
6
7
8
ERROR MESSAGE
WHAT IS YOUR AVERAGE HOUSEHOLD MONTHLY:
ELECTRIC BILL
Select
Use regional average
Under $20 USD (€14 EUR)
$35 USD (€25 EUR)
$50 USD (€36 EUR)
$75 USD (€54 EUR)
$100 USD (€72 EUR)
$150 USD (€108 EUR)
$200 USD (€145 EUR)
$250 USD (€181 EUR)
$300 USD (€217 EUR)
$350 USD (€253 EUR)
$400 USD (€289 EUR)
$450 USD (€325 EUR)
Over $500 USD (€362 EUR)
NATURAL GAS BILL
Does not apply
Under $20 USD (€14 EUR)
$35 USD (€25 EUR)
$50 USD (€36 EUR)
$75 USD (€54 EUR)
$100 USD (€72 EUR)
$150 USD (€108 EUR)
$200 USD (€145 EUR)
$250 USD (€181 EUR)
$300 USD (€217 EUR)
$350 USD (€253 EUR)
$400 USD (€289 EUR)
$450 USD (€325 EUR)
Over $500 USD (€362 EUR)
OIL BILL
PROPANE BILL
DO YOU USE ENERGY
EFFICIENT CFL LIGHTING?
Yes
No
Partial
WHAT % OF YOUR
ENERGY COMES FROM
CLEAN RENEWABLE
SOURCES, SUCH AS
SOLAR OR WIND?
I don't know
Under 20%
30%
50%
75%
100%
ERROR MESSAGE
NUMBER OF CARS
0
1
2
3
4
YEAR
Select
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
ANNUAL USAGE
Under 3,000 mi (4828 km)
5,000 mi (8046 km)
7,500 mi (12070 km)
10,000 mi (16093 km)
12,000 mi (19312 km)
17,000 mi (27358 km)
21,000 mi (33796 km)
Over 25,000 mi (40233 km)
MAKE
Select
MODEL
Select
YEAR
ANNUAL USAGE
MAKE
Select
MODEL
Select
NUMBER OF CARS
ERROR MESSAGE
YEAR
ANNUAL USAGE
MAKE
Select
MODEL
Select
YEAR
ANNUAL USAGE
MAKE
Select
MODEL
Select
OTHER METHODS OF
TRANSPORT
(select all that apply)
TRAIN
BUS
SUBWAY
BICYCLE OR WALKING
TIMES PER WEEK YOU COMMUTE BY TRAIN?
1
2
3
4
5
6
TIMES PER WEEK YOU COMMUTE BY BUS?
TIMES PER WEEK YOU COMMUTE BY SUBWAY?
TIMES PER WEEK YOU COMMUTE BY BICYCLE OR WALKING?
SELECT THE NUMBER OF ROUND TRIP
FLIGHTS, AND LENGTH, PER YEAR
FLIGHTS UNDER 2 HOURS
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
FLIGHTS 2-3 HOURS
FLIGHTS 4-6 HOURS
FLIGHTS 8+ HOURS
CHECK ALL THAT APPLY TO YOUR CURRENT WORK HABITS
I TURN OFF MY MONITOR AND / OR
WORKSTATION WHEN NOT THERE
I MAKE DOUBLE-SIDED COPIES,
WHENEVER POSSIBLE
I RECYCLE PAPER, WASTE, AND
CARDBOARD
CHECK ALL THAT APPLY TO
YOUR CURRENT LIFESTYLE
I SWITCH OFF THE LIGHT UPON EXITING A ROOM
I UNPLUG MY SMALL / LARGE APPLIANCES
I USE A WATER-EFFICIENT SHOWER HEAD
I BRING MY OWN BAGS TO THE MARKET
I BUY "LOCAL" WHENEVER POSSIBLE
I AM A RECYCLER
YOU HAVE COMMITTED TO DO THE FOLLOWING:
I will plant one tree
I will switch to green power
I will change 4 light bulbs to CFLs
I will carpool at least one day per week
I will check my tires every three months
I will ride public transit to work one day per week
I will buy carbon offset the next time I fly
I will turn off my monitor when not in use
I will buy energy efficient electronics and appliances
ERROR MESSAGE
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