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         Last Name (or company name) *  
                          First Name *
                          Address *
 
 
 
                           City
                           Postcode
                           Phone *  
                           Home Phone
                           Work Phone
                           Mobile
                           Fax
                           Email *
                           Notes
              New cylinder required? Yes No
              Cylinder capacity (new & existing)
              Roof pitch estimate
              Roof orientation estimate
              Roof type
              Number of occupants in your home
              Wet back installed or required? Yes No
              Measure current hot water use? Yes No
              Hot water pressure
              Monthly energy cost estimate
        
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