Part 1: Contact Details

Customer Code:    (From Linetrust South Canterbury Letter if applicable)

First Name:           *

Last Name:           *

Address:               *

City/Town:             *

Daytime Phone:     *

Mobile:               

Email:                

Are you the property owner?:      Yes No   *

What is the best time to contact you? (Office Hours: Monday - Friday, 9am - 5pm)

                           Any time Morning Afternoon   *

How did you hear about us?:      Letter/mailout Radio Newspaper EECA Referral/word of mouth Internet search Other    *

Part 2: Home Details

Approximately what year was the home built in?:              *

How many people live in the home, including children?:            1 2 3 4 5 6 7 8 9 10   *

Can the roof space be easily accessed?:      Yes No   *

What is the home's floor type?:            Concrete Wood   *

Can the underfloor space be easily accessed?:      Yes No   *

What is the home's main form of water heating?:            Electricity Gas Wetback Solar   *

What is the home's main form of space heating?:            Fixed electric heater Fixed unflued gas heater Flued gas Heat pump Oil/diesel burner Open fire Pellet burner Portable electric heater Portable gas/LPG heater Wood burner Nightstore No heating   * 

Part 3: Availability

A home energy assessment generally takes 90 - 120 minutes to complete. The assessment covers your home's water and space heating, insulation, lighting and current electricity consumption.

The times I am available for a home assessment are:

                            Morning            Afternoon

                         8.30am - 12pm   12pm - 5pm

Monday                                         

Tuesday                                        

Wednesday                                   

Thursday                                       

Friday                                           

* The last assessment of the day begins at 1.30pm.