Acknowledgement Form

Date

Personal information

Name

Please enter a valid name (letters and spaces only, 2-50 characters)

Please enter a valid email address

Contact number

Please enter a valid phone number (10-15 digits)

Hot water information

Number of heat pump

Please enter a valid number (1-10)

Purpose

Please enter a purpose (5-100 characters)

Existing heat pump

Business information

Business name

Please enter a business name (2-100 characters)

Business Address

Please enter a valid address (5-200 characters)

ABN (optional)

ABN should be 11 digits

Installation Information

I confirm that the heat pump(s) installation at my business property will benefit my business.

Please confirm this statement

I confirm that the Hot water produce by the heat pump installed in my business property will only be use in business Purpose only

Please confirm this statement

I confirm that there is no residential or quarter areas attach at the property

Please confirm this statement

I confirm and have no intention of removing or replacing any part of the heat pump installed in my business property

Please confirm this statement

I confirm that the heat pump can go up to 65 degrees and I am informed about it and agreed to it.

Please confirm this statement

I confirm that $200 needs to be paid for each tank installed in the property and I am not going to get any reimbursement or in any way from the payment I made.

Please confirm this statement