Please enter the address where the fridge will be installed.  Note:  This application is for Lanai residents only.

Street Address *

Address Line 2

Please enter your mailing address (P.O. Box).  Note:  This application is for Lanai residents only.

Street Address *

Address Line 2

Number of people living at this address *

Number of Bedrooms *

Number of Bathrooms *

Average monthly electricity bill *

What is your household's annual income? Less than $25,000
$25,000 - $40,000
$41,000 - $55,000
More than $55,000
*

How many refrigerators do you own? Please list model, year and size. *

Why do you want to participate in Hui Up? *