Department of Licensing and Consumer Affairs 
Electrical Supply Price Survey Form 
 
Name of your Business: 
      ______________________________________ 
Your Business Physical Address: ______________________________________ 
Telephone Number:____________________               Business Number: ___________________ 
Social Security No:_____________________              Tax I.D. No.: _______________________ 
Legal form of Business: □ Corporation □ Partnership □ Partnership □ Joint Venture □ Individual 
                 ITEM                                     UNIT                  LOW                             HIGH 
R/R Electrical Outlets                      
Each 
$___________ 
$___________ 
R/R Service Entry                       
Each 
$___________ 
$___________ 
R/R Smk., Alrm., Hrd., Wrd            
Each 
$___________ 
$___________ 
R/R Electrical Fixtures                     
Each 
$___________ 
$___________ 
R/R Ceiling Fans                              
Each 
$___________ 
$___________ 
R/R Garage Door Openers 
Each 
$___________ 
$___________ 
Electrical Inspection and Estimate 
Job 
$___________ 
$___________ 
 
Total Electrical System Replacement 
                                          ITEM                                   LOW                           HIGH    
R/R Economy 
$_____________ 
$____________ 
R/R Average Quality 
$_____________ 
$____________ 
R/R Good Quality 
$_____________ 
$____________ 
R/R High Quality 
$_____________ 
$____________ 
Over head* 
Include Insurance & Tax 
$_____________ 
$____________ 
Profits* 
$_____________ 
$____________ 
                           
*Provide these figures only if they are not included in the unit cost. 
I hereby certify that the information provided herein is true and correct. 
 
_____________________________       _________________________       ________________ 
Print Name                                              Signature                                         Date