Hospital LED Lighting Retrofit Application Form
Facility Information
Hospital Name
Facility ID (if applicable)
Address
City
State
ZIP Code
Contact Information
Contact Name
Title/Role
Phone
Email
Project Information
Describe Project Scope
Hospital Areas Involved (select all that apply)
Wards/Patient Rooms
Hallways/Corridors
Operating Theatres
Offices/Admin
Laboratories
Emergency Department
Other
Number of Existing Fixtures
Number of Proposed LED Fixtures
Estimated Start Date
Estimated Completion Date
Additional Notes