Synergy SmartWays Home Assessment Booking Form

* Required fields

Home Assessment Form

Personal Details

Synergy Account number:

First Name:*

Last Name:*

Contact phone number:*

e.g. 08 9999 9999 or 0400 000 000

Email address:*

Confirm email address:*

Premise Details

Please enter either a lot number, location number, or house number

Lot number:

OR

Location number:

OR

House number: Please enter the house number without alphabetic suffix. E.g. For house 23A enter "23"

Unit Type: unit type

Apartment Cottage Duplex Factory Flat House Kiosk Maisonette Marine Berth Office Penthouse Room Shed Shop Site Stall Studio Suite Townhouse Unit Villa Ward Warehouse

Unit number: Please enter the unit number without unit type. E.g. For Unit 11 enter "11"

Street name:*

Town/Suburb:*

Postcode:*

State:*

WA

Number of bedrooms:

Number of bathrooms:

Number of adults:

Number of children (under 18 years):

Other information

Do you own the house?

Owner Renter

Does your house have roof insulation?

Yes No Unsure

What fuel is used for hot water?

Natural gas Electric LPG Solar/Gas Solar/Electric Unsure

Type of hot water system:

Storage Instant Unsure

Does the house have a solar photovoltaic system?

Yes No Unsure

Does the house have a rainwater tank?

Yes No Unsure

Does the house have a swimming pool?

Yes No

Once you have completed the SmartWays Home Assessment, Synergy would like to offer you a range of products that are designed to help you save energy and water. Would you like to receive offers on energy efficient products from Synergy?*

Yes No

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