Home Energy Assessment Form - Golden Globe Merchants Ltd

1

Address*

Find Your Address by Postcode

Please enter a valid postcode

Street Address

Please enter your street address

Address Line 2

Town/City

Please enter your town/city

County

Please enter your county

Postal Code

Please enter a valid postal code

2

Name*

First Name

Please enter your first name

Last Name

Please enter your last name

3

Email*

example@example.com

Please enter a valid email address

4

Phone Number*

Please enter a valid phone number

5

Funding Route?*

Government Grant Able to Pay

Please select a funding route

6

Measures Of Interest?*

Select All That Apply

Solar PV Battery Storage Solar + Battery Bundle Air Source Heat Pump (ASHP)

Please select at least one measure of interest

7

Property Type?*

Detached Semi Detached Terraced Bungalow Flat/Maisonette Park Home Not Sure

Please select a property type

8

Roof Type?*

Pitched Flat Unsure

Please select a roof type

9

Roof Covering?*

Tile Slate Metal Unsure Other

Please select a roof covering

10

Any Shading From Trees or Nearby Buildings?*

Yes No

Please select an option

11

Typical Electricity Spend?*

Write average monthly bill, we do not require exact amount

Please enter your typical electricity spend

12

Number Of Bedrooms?*

1 2 3 4 5 5+

Please select the number of bedrooms

13

Current Main Heating?*

Gas Boiler Oil LPG Electric Solid Fuel Heat Pump Not Sure

Please select your current main heating

14

Space For an Outdoor Unit?*

Yes No

Please select an option

15

Hot Water Cylinder Present?*

Yes No Not Sure

Please select an option

16

Which Upgrade(s) are you interested in?*

Home Insulation Heating Upgrades Boiler Upgrade Solar Panel Install Air Source Heat Pump

Please select at least one upgrade

17

Benefits You Receive?*

Select All That Apply

Please select at least one benefit or 'None/Not sure'

18

Home Ownership?*

Homeowner Private Tenant Landlord Social Tenant Other

Please select a home ownership type

19

Current Main Heating?*

Gas Boiler Electric Storage Heaters Direct Electric Oil LPG Solid Fuel Heat Pump None/Not Sure

Please select your current main heating

20

Review & Consent*

Review your details before submitting

Contact

Name:

Email:

Phone:

Address

Line 1:

Line 2:

Town:

County:

Postcode:

Property & Measures

Funding Route:

Measures of Interest:

Property Type:

Roof Type:

Roof Covering:

Shading:

Electricity Spend:

Bedrooms:

Current Heating:

Outdoor Unit Space:

Hot Water Cylinder:

Upgrades Interested:

Benefits:

Home Ownership:

Current Heating (2):

Please tick the box to provide consent

Welcome

Address*

Name*

Email*

Phone Number*

Funding Route?*

Measures Of Interest?*

Property Type?*

Roof Type?*

Roof Covering?*

Any Shading From Trees or Nearby Buildings?*

Typical Electricity Spend?*

Number Of Bedrooms?*

Current Main Heating?*

Space For an Outdoor Unit?*

Hot Water Cylinder Present?*

Which Upgrade(s) are you interested in?*

Benefits You Receive?*

Home Ownership?*

Current Main Heating?*

Review & Consent*

Review your details before submitting