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Cornerstone AC Program
This form is for individuals who would like to see if they qualify to receive a free window AC unit for their house.
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* Indicates required question
Email
*
Your email
Email
Your answer
First Name
*
Your answer
Last Name
*
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Main Phone Number
*
Your answer
Secondary Phone Number
Your answer
Do you currently have a working A/C in your home?
*
Yes
No
Have you received an AC unit from the Cornerstone A/C Program in the past?
*
Yes
No
Do you live in a house?
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Yes
No
Do you live within 30 miles of downtown Dallas?
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Yes
No
Do you own the property where you are requesting the A/C unit to be installed?
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Yes
No
Do you have security bars on your windows?
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Yes
No
Do you have an outlet within 5 feet of a window?
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Yes
No
Do you have young children in the home?
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Yes
No
Do you have an elderly person in the home?
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Yes
No
Do you understand that if you miss the scheduled appointment to install your A/C, a second attempt will not be made and you will not be able to re-add to the list in 2022?
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Yes
No
Do you understand that if chosen to receive a free A/C through the program, you will be responsible for the electrical costs associated with the operation of the A/C unit?
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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